Day and Community Support Service Referral Form Office use only Panel date: _______ Day service – LP, VC, SH Worker/ allocation date______________________ Panel notes: Referral Date: Any Preference? Lovell Park Hub ☐ Name: Stocks Hill Hub ☐ Address: The Vale Circles ☐ Date of Birth: Gender: Community Based (CAT) ☐ Tel no. home: Tel no. mobile: Email: Post Code: Preferred Method of Contact: Emergency contact name: Relationship: Tel: NHS no. Section 117 status: Referrer name: Your role: CPA: Your service: Your tel: Email: Other support services being used: GP name: Surgery: Tel no. Name: Service: Tel no. Name: Service: Tel no. Name: Service: Is the client caring for anyone, if so who? Tel no. Does the client have a Carer, if so who? What are client’s mental health issues? Medication: What are the client’s physical health issues? What would the client like to get out of day services? (you may select more than one) Socialising and Making friends ☐ Volunteering ☐ Sports and exercise ☐ Employment ☐ Women’s Groups ☐ Art and Crafts ☐ Walking/ Out and about groups ☐ Discussion Groups ☐ Education and courses ☐ Gardening ☐ Cinema/ Theatre ☐ Relaxation ☐ Music ☐ Photography ☐ Information ☐ Carers support ☐ One to one support from worker ☐ IT/Computers ☐ Cooking / Baking ☐ Dance ☐ Confidence building/ Anxiety management ☐ Other (please state) Additional information e.g. cultural needs, safeguarding issues, Language issues, disabled access, BSL. Please submit this form with the most recent risk assessment and attached monitoring form as we will not be able to proceed without this information. Post to: The Vale Circles, 12 Tunstall Road, Leeds, LS11 5JF Or Email to: Or Fax to: [email protected] 0113 2775167 Any questions email [email protected] or telephone 0113 3782822 Information about our service and copies of our timetables are available on www.leeds.gov.uk/dcss Day and Community Support Service Referral Form Demographic Monitoring Form We want to make sure that the Adult Social Care Provider Services are delivered fairly. We are therefore asking the following questions about this person, so that we can make sure that our services include everyone’s needs. The information provided will be kept confidential. Gender Female Male Transgender Prefer not to say Was not asked Date of Birth Ethnic monitoring information Ethnic background is not necessarily the same as nationality or country of birth. Please tick which is closest or write a more specific group if you wish. Black or Black British: African Caribbean Other Black/African/Caribbean background Asian or Asian British: Bangladeshi Indian Pakistani Chinese Kashmiri Any other Asian background White: English Welsh Scottish Northern Irish British Irish Any other white background (Please specify if you wish) Other ethnic group: Gypsy/Traveller Prefer not to say Residency British or United Kingdom Citizen Is this person a national of another country, are they Refugee EU National How would you define their housing status? Homeless/Temporary Hostel Supported Accommodation Independent Accommodation Prefer not to say Any other ethnic backgrounds (Please specify if you wish) Was not asked Asylum Seeking Destitute Do not know Was not asked Prefer not to say Others Living Living Living Living Alone with Family with Partner with Others Was not asked Relationship Status Married Civil Partnership Co-habiting Sexual Orientation: Heterosexual Lesbian/Gay woman Gay man Single Other Bisexual Prefer not to say Was not asked Disability – does this person consider themselves as disabled? No Learning Disability Yes Long-standing illness Physical Impairment Prefer not to say Sensory Impairment Was not asked Mental Health Condition Religion/Belief Buddhist Christian Hindu Jewish Muslim Sikh Other No religion No belief Prefer not to say Was not asked Other Professional /Employment Status Voluntary Work Job-search training attended Part-time Employment Employment support meetings/contacts Full-time Employment attended Goal specific training courses attended Service user involvement work Vocational training attended Prefer not to say Was not asked Does this person have caring responsibility for anyone? Partner Others Friend(s) if they have responsibilities for children please Child(ren) give their age(s) Parent (s) Relative (s) Was not asked None Prefer not to say Does anyone have a caring responsibility for this person? Partner Parent(s) Child(ren) Relative(s) Friend(s) Others None If a child under the age of 19 has caring Was not asked responsibility for this person please give their age Prefer not to say Did the person receive information about (If YES please tick) Self-Directed Support Individual Budgets Direct Payments Prefer not to say Carer assessment and support Was not asked To provide the best possible service to a person, we will hold both paper and electronic copies of the information that the person provides to us. This information will be held in strict accordance with the Data Protection Act 1998. We will only use the information for the purposes that we have mentioned and for operational reasons where we are required to do so by Law (e.g. information we are required to provide during an audit).
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