WESTMINESTER REFERRAL FORM

Service Users details

Surname

/ Forename/s
Alternative Names / Title / DOB
Marital Status /

Gender M/F

/ Age
Address
Tel / Minicom / Fax

Preferred Language

Verbal/Signing ……………………....……. Written…………………..…..….…… ….
Is interpreter required? Yes  No  If yes, please state language......
Preferred Methods of Communication (please tick)
British Sign Language (BSL) Speech Lip-reading Deaf-blind manual  Sign Supported English (SSE)Other please state .………………………………… Lip-reading(please tick)
Total reliance Supplement hearing Little or no ability

Next of Kin

Surname / Forename/s

Address

Tel / Minicom / Fax

Other significant family/carer/relationships & their contact details

Health- please give the following details

Name and Address of GP

Name
Address
Tel / Minicom / Fax

Name and Address of Audiology Consultant/ Audiologist

Name
Address
Tel / Minicom / Fax

Details on Deafness/Hearing Loss

Age of Diagnosis (where possible) …………………………………………………….…….

Hearing aids prescribed:Yes No Type ….……………………………....

Where prescribed? ……………………………………. When issued? ……………………
(e.g. clinic, hospital, shop)
When are they used?
Used (please tick)Ear Mould (please tick)
All the timeClean
OccasionallyWax
Not usedGood fit
Other………………………………..Loose
Repair/Battery Replacements (please tick)

Able to collectYes No 

Dependent on others Yes No 
Degree of Loss (Guidance only, if audiogram available please complete section)
RightLeft
a) Profound (Over 95 db loss)
b) Severe (71 - 95 db loss)
c) Moderate (41 - 70 db loss)
d) Mild (21 - 40 db loss)
(Source: Degree of loss, averaged over the frequencies 500hz-4kHz, BATOD – British Association of Teachers of the Deaf)
Communication/Speech
Hearing (please tick)AidedUnaided
1. Very good
2. Good
3. Poor
4. Completely deaf
Communication – How easy is it for hearing people to understand you? (please tick)
No problems / 
Slight difficulty / 
Moderate difficulty / 
Understood by certain people / 
Severe difficulty / 

Details on Deafness/Hearing Loss

Hearing ability – whether you can hear in these situations? (please tick)
Is it difficult to hear when unaided? Yes  No Sometimes 
None at allYes when aided Yes unaided
Without With Without With
Difficulty Difficulty
1. Group situations    
2. One to one   
3. Television   
4. Door bell alerter    
5. Telecommunications   
6. Alarm clocks   
Is it still difficult to hear when aided? Yes  No Sometimes  
Please write additional information in comments section below.

Comments and recommendations for Equipment needs identified:

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Signature details
I agree that the information given may be used for the purpose of registration/ equipment assessment.
I give my permission for this referral to be passed onto Westminster Social Services and Audiology Department (where applicable)
I would like my details to be passed onto deaf/ hard of hearing organisations?
YesNo
I understand that any information contained on this assessment form may be held in computer files under the terms and conditions of the Data Protection Act 1984.
Signed...... …….....Date...... ………………......
Ms/Mrs/Miss/Mr*Name:...... ……………...... …….…………………….…..….....
Service User/ Representative*) * delete as necessary
If representative, please state relationship ...... …......

Deaf OR Hard of Hearing Registration

Is this person eligible for registration? (please tick) Yes  No 
(if unsure, please leave this blank and send it to Marie Webb-Stevens)
(please attach a copy of the Audiogram if this Service User is under the age of 65)
Register this person as (please tick the relevant box):
Deaf
People who have little or no useful hearing, even when using a hearing aid.
Hard of Hearing
People who have some useful hearing and whose usually communicate using speech, listening and lip reading – with or without a hearing aid.
Assessment Worker/Referrer (print name)
Signature of Assessment Worker/Referrer
Address:
Tel: / Minicom: / Fax:

Please keep a copy of the registration in the client’s file and send the original to:

Marie Webb-Stevens, Deaf and Hard of Hearing Specialist Worker, Adults Services, 9th floor, City Hall, 64 Victoria Street, London SW1E 6QP or fax to 020 7641 3902/3167.

For office use only:
Details entered on SSID System Yes  No  / SSID Party ID:
If yes state date / Entered by:
Team Manager Signature:

What is your ethnic group?

Westminster Social & Community Services would like to record your ethnic group. This will help us to see whether all sections of the community have equal access to services and will help us to better plan our services to meet your needs. ‘Ethnic group’ describe how you see yourself and is a mixture of culture, religion, skin colour, language and the origins of yourself and your family. It is not the same as nationality. The categories below are based on those used by the Commission for Racial Equality and those used in the 2001 national Census.

Please consider first the broad ethnic group that you feel you belong (those in BOLD CAPITALS) and then tick the box within that group which you feel is most appropriate for you.

WHITE
British
Irish
Other European
Any other White background / MIXED
White & Black Caribbean
White & Black African
White & Asian
Any other mixed background
BLACK OR BLACK BRITISH
Caribbean
African
Any other Black background / OTHER ETHNIC GROUP
Chinese
North African
Arab
Middle Eastern
Any other ethnic group
ASIAN OR ASIAN BRITISH
Indian
Pakistani
Bangladeshi
Any other Asian Background / Not willing to specify
This information will be used for service planning and will be treated in the strictest confidence.

Updated by M Webb-Stevens – 2009

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