Together Norfolk Support Services Referral Form

The Norfolk service provides county-wide support to adults with mental health needs to access and maintain their accommodation.

Before making a referral, please read the document entitled “Together Norfolk Services, Service User Eligibility, Priority & Referral Pathways Information Form” This document gives detailed information regarding the Norfolk services and will aid you in completing this referral form and help you in your decision to refer to Together Norfolk.

This referral form must be completed in full, including obtaining the consent of the potential Service User. If these conditions are not met, the referral form will be returned to the person making the referral.

Date of referral
CCG Area:
Norwich City, South Norfolk, North Norfolk, East Norfolk, West Norfolk.
Person Needing Support / Title / First name / Surname/ family name
Date of birth
Address including postcode
Telephone number: landline
Telephone number: mobile
Email address
Preferred method of contact
National Insurance Number
If an interpreter is needed, which language?
Referring Agency / Please ensure you have provided your full contact details including name, contact number and email address.
Referrers name/ job title
Organisation/Address
Telephone number: landline
Telephone number: mobile
Email address
GP
GP Name
GP Surgery name
GP Surgery address
Diagnosis (please include mental health and physical health issues)
Medication
Subject to MHA S117 Aftercare or Community Treatment Order?
Details of Care Coordinator or other relevant agencies involved in care. For example social worker, community mental health nurse, probation officer, debt agency.
Type of accommodation
(e.g.; own property, private tenancy, housing association, local authority)
Landlord name and address
Any rent or mortgage arrears? / If yes, please give details
At risk of homelessness within 28 days? / If yes, please give details
Please list current income/benefits
Any debts? / If yes, please give details
Any court action/ bailiffs? / If yes, please give details
Please give full details of reason for referral and support required
(if not completed, this referral will be returned)
Yes/No / Please give full details
Sensory impairments
Physical disabilities
Carer(s)
Any pets?
Is there a gender preference regarding workers?
Next of kin / Name and contact details
People who live at the same address

Risk information

Yes/No / Please give details
Is it safe to visit at home?
Any incidents of anti-social behaviour, harassment, neighbour nuisance? (towards others or by others)
Suicidal thoughts/attempts
Substance use
Alcohol misuse
Verbal aggression to/from others
Physical aggression to/from others
Exploitation of others/ by others
Sex offenders register
Smoking arrangements
I agree to one or more of the options listed below in order to support Together’s health & safety obligations to staff & volunteers (please tick as appropriate)
·  I will not smoke whilst Together staff are supporting me in my home □
·  I agree to smoke in another room whilst Together staff are in my home □
·  I do not smoke □
Additional Documentation
Is there any other documentation attached to this form?
If yes please name and state source:
I am aware of this referral application and give my permission to share this and other information on a need to know basis with relevant agencies relating to this referral.
Applicant signature...... Date......

Please email the completed referral form to:

If you are unable to email, please send by fax to: 01603 403 025

Or by post to: Together Norfolk

Suite B, Sapphire House

Roundtree Way

Norwich

Norfolk

NR7 8SQ

Telephone number: 01603 485095

Publication Date: May 2017 Review date December 2017 Page 2 of 4