Referral Form

Please complete the form below and click 'submit', or you can contact me directly,
Mustapha Elahee, Project Manager, on 07984 818399 or via email at mus@filey.care

Service Users' Details

Name:

D.O.B:

Age:

Current Address:

Tel. No.:

Religion:

Ethnicity:

Email:

Next of Kin or Guardian Details

Name:

Current Address:

Tel. N.O.:

Relationship:

Referring Agency Details

Name of Referrer:

Job Title:

Agency Name & Address:

Tel. N.O.:

Mobile N.O.:

Email:

Fax. N.O.:

Is Funding Approved:
 Yes No

Referral Timescale

We aim to see a prospective tenant within 5 working days. If the referral is urgent and needs to be seen within 2 working days, please tick this box 

What are the best days, time and place for us to meet with your client?

OR

Do you want to visit the supported housing scheme(s) first with your client:
 Yes No

Do you want to visit the supported housing scheme(s) first without your client:
 Yes No

Presenting Issues

PRIMARY (TICK ONE ONLY)

 Mental health/personality disorder
 Aspergers syndrome
 Learning disability
 Physical disability
 Brain injury
 Alcohol misuse
 Drug misuse
 Care leaver
 Homelessness

SECONDARY (TICK ALL THAT APPLIES)

 Mental health/personality disorder
 Aspergers syndrome
 Learning disability
 Physical disability
 Brain injury
 Alcohol misuse
 Drug misuse
 Care leaver
 Homelessness

OTHER ISSUES : Please detail other presenting conditions that are identified OR submit up to date reports with details:

Please indicate if report(s) are to be sent by: Fax  Email  Post  N/A 

Care & Support Required (Tick all that apply)

Does he/she require assistance with any of the following areas? Please indicate level of assistance required
H= High, M=Medium, L=Low, N= None

Budgeting  H  M  L  N
Paying bills  H  M  L  N
Accessing benefits  H  M  L  N
Domestic life skills  H  M  L  N
Personal hygiene  H  M  L  N
Health & safety in the home  H  M  L  N
Escorting  H  M  L  N
Accessing social &
recreational activities
 H  M  L  N
Language and or literacy  H  M  L  N
Access to education
& employment
 H  M  L  N
Behavior/anger management  H  M  L  N
Medication/prescriptions  H  M  L  N
Registering with primary care services  H  M  L  N
Physical health care problems  H  M  L  N
Nutrition/weight  H  M  L  N
Family mediation  H  M  L  N
Neighbours/peer mediation  H  M  L  N
Vulnerable to exploitation  H  M  L  N
Mobility  H  M  L  N
Religious/cultural  H  M  L  N

OTHER ASSISTANCE REQUIRED : Please detail other identified care and support needs OR submit up to date care or pathway plans with details.

Please indicate if latter to be sent by: Fax  Email  Post  N/A 

Risk Assessment

Arson  High  Medium  Low  N/A
Physical violence (to others)  High  Medium  Low  N/A
Drugs/Substance abuse  High  Medium  Low  N/A
Sexual behaviour (risk to others)  High  Medium  Low  N/A
Self harm/Overdose  High  Medium  Low  N/A
Alcohol abuse  High  Medium  Low  N/A
Damage to property  High  Medium  Low  N/A
Verbal Aggression  High  Medium  Low  N/A
Criminal behaviour  High  Medium  Low  N/A
Sleep disturbance/Nocturnal difficulties  High  Medium  Low  N/A

OTHER RISK ISSUES : Please detail other known risk to self or others OR submit up to date Risk Assessments with details

Please indicate if latter to be sent by: Fax  Email  Post  N/A 

We operate a Lone Workers Policy for outreach support workers; if you are aware of any reasons why this may be unsafe, please state below:

Contact Details of other Agencies involved in the clients care or supervision

Name & Address of Agency

Name of contact & telephone number

Any Other Relevent information



Filey Care and Support Ltd. Head Office: 276 Hertford Road, Edmonton, London, N9 7HE