Referral Form.

Moving on Together Community Integration delivered in partnership with;

Referral criteria for momentum services
·  Adult or child with an acquired brain injury or neurological condition
·  Must be motivated to change and to work towards structured goal plans
·  Must want to engage with their community or returning to work/education/voluntary roles
·  Family members of children with a brain injury/neurological condition who need advice and support
Unfortunately we are unable to support;
·  Clients whose mental health problem is not related to their brain injury/neurological condition
·  Clients who have a complex mental health presentation e.g. psychotic symptoms, schizophrenia or bipolar disorder
·  Clients who require significant adjustment support in the community
·  Clients who engage in substance misuse including alcohol
·  Clients who are a risk to self or others
Lone/Home Visit suitable? Y / N. If no, please state reasons;
Please attach any additional information to support with referral;
-  Psychological interventions
-  Ongoing support
-  Risk Assessments
Please tick the service you are referring to:
□ Moving on Together/ Community Integration: covers North East
Person centred service for adults and children focusing on the reduction of social isolation and management of conditions through social support groups, 1:1 support, transitional support, family counselling and psychological interventions.
Staff contact: Kate Riddler:
□ Vocational Rehabilitation Programme:
Session Based/Work Placement/Personal Development
A structured three day per week programme based in Newcastle for adults of working age who require specialist support to gain employment/training/education. MDT includes Clinical Neuropsychologist, Assistant Psychologists, Job Coaches and Tutor. Sessions include Vocational Exploration, Social Skills, Psychology & Cognitive Training.
Staff Contact: Christopher Liu :
□ Domiciliary Care / Community Rehabilitation Service: Whole North East
Individualised goal-directed rehabilitation increasing independence in social, domestic and community activities. Psychological intervention to manage cognitive, emotional and behavioural effects. 24 hour personalised and individualised personal care and support packages
Staff Contact: Paul McKay:
Date of referral: Staff Initials:
Name of referrer:
Job title / Relationship to Client:
Organisation:
Address:
Tel:
Mobile:
Email
Would you like to be involved in the assessment process?
Name of Service User:
D.O.B:
Date of injury/diagnosis:
Nature of injury/diagnosis:
Address:
Area (please circle): Newcastle, North Tyneside, Northumberland, South Tyneside, Gateshead, Sunderland, Durham, Teesside, Middlesbrough
Tel:
Mobile:
Email:
NI Number: NHS Number:
Service User’s GP Name & Address:
Reason for referral (e.g:, cognitive ability, present mobility, psychological well-being, daily & social functioning).
Client Goals/wants from the service?
Currently Employed: Y / N
Is the Service User interested in returning to employment/education?
Please circle: Paid Voluntary Self-employed Training/education.
Further Details:
Support needs:
Other Services Involvement: Y / N. (Provide details).
Has the referral been discussed with the Service User? Yes No
Has the Service User consented to referral? Yes No
Does the Service User require support for the initial assessment? Yes No
(If so please provide carer details)
Next of Kin Name:
Address & Telephone No:
TO BE COMPLETED BY STAFF.
Follow-up Phone Call.
Date: Staff Initials:
Initial Assessment Booked.
Date: Staff Initials:

Please return this form to: Momentum Skills, Floors 1 & 2, Forth Banks House, Skinnerburn Road, Newcastle-upon-Tyne, NE1 3RH. Tel: 0191 232 0234, Fax: 0191 230 4307.