Client Self-Referral Form

 
For Birchtree Housing CIC to be able to assess the client holistically, ensuring that all elements are considered, it is vitally important to have all of the relevant information about the client’s needs, and wants. This will enable the client to be placed in the right environment, and provided with the individual support they will need to firstly sustain their accommodation, adhere to their licence and to develop the skills they need to eventually when ready to move on to being fully independent, in the community.

 

Please note: All clients will have a 30 day probation period to ensure that the service is the most appropriate for them.

 

This form to be used only for Birchtree Housing CIC referrals:

Guidance and information:

  • Please give clear information about the client
  • Please attach the required documents listed below to the automated reply email you receive once the form has been submitted
  • We aim to respond within 72 hours

 

Documents required:

  1. Proof of ID
  2. Proof of Benefits
  3. Proof of National Insurance number
  4. 1 month bank statement
  5. If in employment (please provide payslips)

 

Birchtree Housing CIC

Telephone: 020 8191 8797

Email: info@birchtree.care

 

Required fields are marked with *
Name Of Referrer*
 
Position*
 
Referrer Email*
 
Organisation Name*
 
Organisation Address
 
Organisation Telephone*
 

Section One: Personal

Name of Client:*
 
Date of birth:*
 
Nationality:*
 
Ethnic origin:*
 
Religion:*
 
Present Home Address:*
 
Telephone:*
 
Previous location:*
 
National Insurance Number:*
 
Benefits received and the amount paid to you:*

(please note: clients should be in receipt of a benefit other than housing benefit to be eligible and must have proof of benefits available.)

 
Does the client have an assigned Social Worker or Community Psychiatric Nurse?:

If applicable, please give details:

 

Section Two: Next of Kin contact details

Next Of Kin Name:*
 
Relationship:*
 
Address:*
 
Telephone:*
 
Mobile:*
 

Section Three: Medical and Psychiatric detail

Diagnosis:*

Please be as specific as possible

 
Existing Related Symptoms: *

Please give details

 
Mental Health Section (if applicable) Has the client been diagnosed with a mental health condition?
Has the client had a mental health assessment, if yes please provide details
 
Are they at risk of suicide?
Do they have suicidal thoughts?
 
Medication currently prescribed: Please give full details
 

Section Four: Drugs/Alcohol Use

Please give full details
 

Section Five: Behavioural Issue

Please give as much detail as possible
 

Section Six: Criminal Offences

Please give details:

Offence: Custodial Sentence: Where was the Sentence served? Length of sentence: Dates:
 
 
 
 
 

Section Seven: Support Needs

In the referrer's opinion what care, support or supervision requirements does the client have?
 
Do they need support with debt management?
Do they have any current debts? Please provide details.
 
Does the client have social interaction issues?
please give details
 
Describe any problems encountered by the Client with daily living activities:
E.g. cooking, cleaning, taking medication, going out, using public transport, laundry, shopping, budgeting, personal hygiene.
 

Section Eight: Risks to be noted

Please give details of any risks that need to be taken into consideration in addition to completing the risk assessment at the end of this form:
 

Section Nine: Bank details

Bank/Building Society/Post office Name:
 
Savings Account info: (Which bank account, and how much?)
 

Risk Assessment Checklist - (tick all relevant columns where a risk is identified, please indicate whether it is HIGH, MEDIUM OR LOW RISK based on knowledge of the Service User)

 

Risk to Self
Risk Factorhighmediumlow
Self Neglect
Abuse by others/financial abuse
Non-compliance with medication
Drug misuse
Self injury behaviour
Alcohol abuse
Anti-social behaviour
Non-engagement with staff
Suicide
Falling
 
Risk Factorhighmediumlow
Wandering
Choking
Mobility on stairs
Road sense
Environmental risks
Medical problems
Sensory disabilities
Ingesting substances
Other
Risk to Others
Risk Factorhighmediumlow
Violence to family members
Violence to staff
Violence to other residents
Violence to general public
Violence from a third party
 
Risk Factorhighmediumlow
Threat to children
Sexual offences
Inappropriate behaviour
Other
Risk on transport
Risk Factorhighmediumlow
Seatbelts
Lift on bus
 
Risk Factorhighmediumlow
Moving around on bus/train
Risk related to property
Risk Factorhighmediumlow
Arson
Damage to property
Theft
 
Risk Factorhighmediumlow
Rent Arrears
Abandonment
Interference with electricity/gas
Details of any risks identified as medium or high
 
Any special precautions
 
Other Risks (Please Specify)
 
Referrer: How long have you been working with this client ?