Referral for Assistive Technology and Just Checking Annex 1 to Contact Assessment

Client name / Gender / M / F / D.O.B / DD/MM/YY
Address
(including postcode)
Telephone number
Alternative
Contact Name:
Relationship to client
Telephone number
Referrer Details
Name
Address
Job Title
Organisation
Contact Number / Email

Funding Type – Please tick and complete as necessary

Private / KMBC
All Telecare referrals should be privately funded and referred directly to Home Care Link unless the service user refuses or is unable to pay the monitoring charge, in which case a commissioned service can be considered. / If a commissioned package is considered, team manager approval is required.
Is the Client aware there is a monitoring charge? / Team Manager approval
Name
Yes / No / Client swift number

Telecare – please tick and complete details below for all Telecare referrals

New Install / Additional sensors / Re-assessment
Type of sensor / to support

Hospital / Intermediate Care / Respite Discharge Only

Name of Hospital or Unit
Length of Stay and Discharge date
Reason for admission

Quick Checklist

Does the client have a working landline telephone? / Yes / No / Don’t know
Is there a power point on the same wall as the main phone point? / Yes / No / Don’t know
Does the client agree to assessment and connection to the service? / Yes / No / Don’t know
Does the client/family consent to sharing their care plan/contact assessment with Home Care Link / Yes / No / Don’t know

If a keysafe is required please refer to Care and Repair via KAT customer service 0151 443 2600

Just Checking – Short term activity assessment tool 4 to 8 weeks use. Social worker referral only.

Brief reason for request
Email addresses of person(s) with permission to view data. Social worker must obtain service user consent for this. / Email / Relationship to Client
Any other information

Declaration

Even if someone else has filled in this form for you, you must sign this declaration if you can. Please read this declaration carefully before you sign and date it.

I understand the following:

·  You will use the information I have provided to process my referral for Telecare. You may check some of the information with other sources as allowed by the law such as Government departments, local authorities and private sector companies.

·  You may give some information to other organisations, such as Government

Departments, local authorities and private sector companies such as banks and

Organisations that may lend me money, if the law allows this.

I declare the information I have given on this form is correct and complete.

Please sign as appropriate

Signature / Print Name / Date
Signature Of client
On behalf of the client
Signature of Referrer

Please e-mail this form to Home Care Link at:

Referral / Admin Enquires: 01695 585224 Phone: 0800 566 666 (clients only)

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Version 2 06/16 HA