Referral Form for Rebuild My Life – Crisis Support

Birmingham Rathbone guarantees confidentiality of information received within legal requirements of the Data Protection Act. If you are sending us sensitive information electronically, you may want to consider using password protection or encryption.

Name
Date of birth / Age
N.I. No
Present Address
Home Telephone Number
Mobile Telephone Number
Email
What is the nature of the Learning Disability/Difficulty?
Please state the nature of the Crisis and any other relevant information to support the referral and the reason why the referral has been made.
Is applicant in Local Authority care or currently receiving a care package?
If Yes please provide details / Yes / No
Social Worker’s Name
Social Worker’s Office Address
Telephone Numbers
Email
Does the applicant have a recognised appointee for finances/benefits? / Yes / No
If yes, please give details of who appointee is:
Doctor’s Name
Doctor’s Address
Doctor’s Telephone Number
Medical information and details of any specific health problems
BENEFITS
Does the applicant get Disability Living Allowance(DLA)? / Yes / No
If yes, please indicate below type and level of DLA / Date awarded
Care / High / Middle / Low
Mobility / High / Middle / Low
Does the applicant getPersonal Independence Payment (PIP)? / Yes / No
If yes, please indicate below type and level of PIP / Date awarded
Daily Living / Standard / Enhanced
Mobility / Standard / Enhanced
Does the applicant get any of the below? (Please  relevant benefit)
Job Seekers Allowance (JSA)
Employment Support Allowance (ESA)
WRAG Group
Support Group
Income Support
Working Tax Credits
Child Tax Credits
Universal Credit
State Pension
Private Pension
Learner Discretionary Fund
Disability Bus Pass
Does the applicant get any of the housing related benefitslisted below? (Please  relevant benefit)
Housing Benefit
Council Tax Benefit
Discretionary Housing Benefit
Does the applicant get any other benefits? (please list below)
Does the applicant currently attend any of the following? (Please  below)
Employment –Full or Part time / VoluntaryWork / Training / Education / Other
Employment/Voluntary Work
Employer Contact Name
Employer’s Address
Employer’s Telephone Number
Number of Hours Employed
Current Salary/Wage
Education/Training Provider
College/Training Provider Contact Name
College/Training Provider Address
College/Training Provider Telephone Number
Number of Hours attendingper week
Please state any other relevant information regarding Employment or Training or College
Has the applicant any history of the following?:
Mental health treatment / Yes / No
Criminal convictions / Yes / No
Self Harm / Yes / No
Alcohol/Substance misuse / Yes / No
We can currently provide support to people with learning disabilities in the below areas.What level of support do you feel you need to meet your current needs to achieve your goals? Please circle/highlight/ the most appropriate:
Support in setting up and maintaining a home/tenancy / High / Medium / Low
Support in developing domestic and practical skills / High / Medium / Low
Support in accessing health and social care services / High / Medium / Low
Support in developing social skills/managing behaviour / High / Medium / Low
Advice, advocacy and liaison with statutory agencies / High / Medium / Low
Support in managing finances and/or dealing with benefit claims / High / Medium / Low
Emotional support, counselling and advice / High / Medium / Low
Support in gaining access to other services e.g. training / High / Medium / Low
Support in establishing social contacts and activities / High / Medium / Low
Support with home improvements / High / Medium / Low
Support in establishing personal safety and security / High / Medium / Low
Support in managing risk in the community / High / Medium / Low
Supervision and monitoring of health and well being / High / Medium / Low
Peer support and befriending / High / Medium / Low
Support finding other accommodation / High / Medium / Low
Next of kin/parents / High / Medium / Low
Siblings / High / Medium / Low
Relationship with peers / High / Medium / Low
Relationship with authority / High / Medium / Low

NB. Birmingham Rathbone’s “Rebuild My Life “ project may at some point access or refer on to other appropriate and/or partner organisations, to provide the best and most appropriate support. This would mean sharing this referral information with them. Please ensure you sign below to give consent.

Consent
I understand that this information may be used by my service provider and Rebuild My Life approved support organisations to provide me with services appropriate to my needs.
Name:
Signature:
Date:
Submitted by (please print name of person completing form)
Relationship to applicant and/or Organisation
Address
Work/Home Telephone Number
Mobile Telephone Number
Email address
Does the applicant consent and is aware of this referral? / Yes
No
Signature
Datereferral submitted

Please return your completed referral form, including the accompanying diversity monitoring form, to the following address:

Birmingham Rathbone

Morcom House

Ledsam Street

Ladywood

Birmingham

B16 8DN

Alternatively scan and email the referral form including the diversity monitoring form to

Document No: RML/Referral/Document1/July 2017 Page 1 of 8