Warm Home Healthy People

Referral Questionnaire

Householder’s Details
Family Name / First Name
DOB / Male Female
Address
Post Code: / Tel / Email
Household Tenure (please pick one)
Private Tenant / Council Tenant / Owner Occupied / Housing Association
Household details
Any children under 16? / Householder aged 55-74? / Householder aged 75+?
Is householder deaf? / Is householder disabled?

Claiming Benefits?

Yes No

Has client had any benefit problems (e.g. refusals, trouble applying)?

Does anyone in the household have a disability?
If so which? :
Falls and health
Is there a history of more than one fall in the past 12 months? / Yes
Does the client have a diagnosis of: Cardiovascular/heart disease?
Respiratory disease?
Parkinson’s disease?
Dementia? / Yes
Yes
Yes
Yes
Is the client on 4 or more medications? / Yes
Does the client report any problems with their balance? / Yes
Is the client UNABLE to rise from a chair of knee height WITHOUT using their arms? / Yes
Ethnicity
White / North African, Arab, Iranian / Mixed / Asian or Asian British
Chinese / Black or Black British / Other (state)
Other Comments

Referred by

Name / Team / Whittington Hospital RRTIntegrated Assessment NorthIntegrated Assessment SouthIntegrated Assessment CentralCare Management NorthCare Management SouthCare Management CentralResidential and Nursing ReviewSensory Disability I CareWhittington HospitalUCL HospitalMental Health Care of Older PeopleREACH - Community Rehabilitation Northern HCHornsey Rise HCGoodinge HCHighbury GrangeRiver PlaceCity Road Killick Street HCFinsbury HCILDP
Job Title / Care Manager/SWCommunity Care AssessorOccupational TherapistCommunity NurseLead AssessorKey WorkerTeam Manager / Tel No
Email / Mobile
Householders Signature / Date
Householder has verbally consented to this referral / Date

Please email to:

Tel: 020 7641 3026
fax to 020 7641 8504

Public Protection and Licensing
Westminster Home Improvement Agency
Residential Services

Westminster City Hall
5th Floor,

64 Victoria Street,
London

SW1E 6QP

1

WHHP referral form 29/09/2016