The Referral Covering Letter Tells You What Happens Next

Referral Form

/ Name of person
/ Date of birth
/ Address
/ Contact Phone Number
/ Email Address
Do you consider yourself to have a learning disability

Yes No

If you are filling the form out on behalf of someone else, can you please tell us your name and contact details

/ Your name
/ Address
/ Contact Phone Number
/ Email Address
/ Your relationship to person being referred
/ Has the individual consented to this referral being made

Yes No
If person is unable to consent please state why this referral is in their best interests

Is there anyone else we should contact when dealing with this referral? If so please put their details below:

/ Their name
/ Address
/ Contact Phone Number
/ Email Address
/ Their relationship to person being referred
/ How can Mencap Liverpool work with you to make things better?
/ Please tell us about people or organisations who are already involved with helping you (please give names and contact details where possible)

Social worker

Organisation/charity

Learning Disability Nurse

Friends/Neighbours
Other Providers
/ Please tell us how you like to communicate (how can we help you to understand the information we have)
/ Please tell us if there’s anything we should know about your physical mobility
/ Please tell us if you have any medical issues
/ Is there anything that makes you very upset or angry?
/ Do you sometimes act in a way that puts yourself or others at risk?
/ Is there anything else you would like to tell us?
/ Are you already a member of Mencap Liverpool? (Do you get our newsletter in the post?)
Yes No

The referral covering letter tells you what happens next

If we start working with you, we might need to ask you for more information so we can work with you in the best way. We may need to share your information with the Mencap Liverpool team, workers who may also be able to work with you

We won’t pass any information about you to anybody else, unless you tell us that it’s ok to do so.

We are a small team and we don’t get funding from National Mencap. Our service is free, but we are very grateful for any donations so we can continue working with people in the way we do. September is our membership month, and we may ask you to pay £15 then if you have been working with us for a year.

Please sign the form to show that

1. The information you have written is correct

2. You have read and understood the notes on this page

Signed Date