Enrych AssistPersonal Assistant Support Service - Confidential
Self Referral and Enquiry Form
If you want to find out more about having a Personal Assistant, please fill this in so we know more about what you are looking for. You can ask a family member or friend to help you.
In East Midlands: Please return to or Enrych, Marlene Reid Centre, 85 Belvoir Rd, Coalville, LE67 3PH. 01530 832 926 for any queries.
In Oxfordshire: Please return to katie.spyve @enrych.org.uk or Enrych, E14 Holly Farm Business Park, Honiley, Warks, CV8 1NP. 07720 089 477 for any queries.
If you fill in this form on a computer, type in the shaded areas. To move to another shaded area, use the ‘Tab’ key or the left and right arrows on the keyboard. Or you can click/tap to select.If you want to writewith a pen and need more space, it is fine to use a new sheet of paper.
My contact details
Preferred Title First name(s) SurnameAddress:
Post Code: / Date of Birth (dd/mm/yyyy)
Telephone - Home:
Telephone - Mobile:
Email address:
Best ways to contact me:
I prefer being contacted by (click on the box to select)
home phone mobile phone email other
Best time of day (eg after 10am, between 9 and 2pm etc)
Days available
How did you hear about Enrych?
My contact people in case of emergency
1st contact name: / Relationship to me:Tel NosHome Work Mobile
Address:
Post Code:
2nd contact name: / Relationship to me:
Tel NosHome Work Mobile
Address:
Post Code:
Please tell us about yourself
Please tell us about your disability. What is your disability and how does it affect you? Please include any condition that is not immediately obvious, but which may be relevant to an activity eg epilepsy, agoraphobia, diabetesPlease tell us about your interests and the things you like doing
Are there other issues, circumstances or conditions that we need to know about? (Eg things that might affect behaviour, social interactions, anything regarding safeguarding issues)
About having a personal assistant
What activities/tasks do you want your PA to support you to do?How many hours of PA support will you need each week?
Please list the days and times you need:
Do you have a local authority Support Plan? Yes No Don’t know
How will you pay for your PA support?
Personal Budget (direct/cash payment) Personal Budget (LA managed service)
My own money Other
Other agencies involved in my care
Name of organisation / Contact person / Phone / EmailCare Manager
Yes I agree
It is OK for Enrych to store information about me while they are working with me. It will be kept safe and confidential.
It is OK for Enrych to contact my social worker, contact person or other health workers about me. But only if it is about my Enrych support needs.
My signature: Name: Date:
If you email this back to us, you can just type your name – we will take that as your signature
Thank you! Now please send this back to us at Enrych. You can email it or post it – address on p1.
Part 2: This is for Enrych to fill in with you(don’t fill it in now)
What’s important to meThings I want my PA to support me to do / What difference will this make to me?
Information relevant to risk assessment
This role involves Manual Handling Food preparation Use of car
Other...
Tasks required
ShoppingYes NoAssist in/out of vehiclesYes No
CleaningYes NoAssisting in leisure activities e.g. swimmingYes No
Preparing mealsYes NoDriving activities e.g. visit friends/hospitalYes No
Any other tasks please specify:
Relevant medical history (physical and mental health):
Triggers and indicators:
Coping strategies and techniques:
Relationships:
Current support in place:
Additional PA training requirements: (eg Epilepsy, Moving and Handing, Food Hygiene)
For Enrych use
Date / Details / Enrych workerPA Self Referral and Enquiry Form Ev5 page 1 of 4