1. Referral Information

Date received by WILS:

 /     / 20

Date of Referral:

Referring Agency:

Contact Name at Referring Agency:

Relationship to person being referred:

Telephone Number:

2. Client Details

Title:

Address:

Forename:

Surname:

Post Code:

D.O.B:

         /         /19

Age:

NI Number:

Tel Number:

Ethnicity:

Gender:

3. Reason For Referral/Help Required

(Continue on additional sheet if necessary. Describe current difficulties and indicate any risk factors or urgency)

Does the person require support with the following:

Help setting up/maintaining home or tenancy

Support in managing finances and benefit claims

Advice, Advocacy and Liaison

Support with shopping, errand running and good neighbour tasks

Emotional Support, Counselling and advice

Access to local community organisations

Support in establishing social contacts and activities

Support maintaining the safety and security of the dwelling

Supervision and help in monitoring of health and well being

Support in establishing personal safety and security

Liaison with drug/alcohol services, probation, counselling services

Support finding other accommodation

Support in gaining access to other services

Advice and support on repair work/home improvement work

Peer support and befriending

Support in gaining access to other services

Does the person consent to the referral being made?

Yes

No

4. Other Information

Significant concerns/ problems with any of the following

Alcohol misuse

Mobility

Substance misuse

Vision

Physical aggression

Hearing

Verbal aggression

Speech/Communication

Suicide attempts

Memory Loss

Self Injurious behaviour

Incontinence

Behaviour

Other

Comments:

Does the person have any previous convictions (spent or unspent)?

Yes

No

If yes please specify:

General Practitioner:

Surgery:

Telephone Number:

Medical Conditions/ Ailments

5. Next of Kin/Relevant others (Support or Professionals involved)

Next of Kin:

Address:

Telephone:

Name/Relationship:

Address:

Telephone:

Name/Relationship:

Address:

Telephone:

6. Additional sheet

Signed____________________________________________ Print Name______________________________