APPLICANT'S DETAILS

Thank you for your interest in our services, this application form should be completed by any support worker who wishes to refer a potential trainee to any of our social enterprises.

Area Applicant Interested in:
How did you hear about us?:



Address Street:
Address City:
Borough:
Address Postcode:



Date of Birth:
Gender:
Gender - self description:
Emergency Contact Name:
Emergency Contact Phone Number:
Emergency Contact Email:
Is this applicant's home address?:
Home Address Street:
Home Address City:
Home Address County:
Home Address Post Code:

MAIN SUPPORT CONTACT FOR TRAINEE

Referrer's name:
Organisation/department/team:
Role in relation to applicant:
Support Phone:
Support E-mail:
Support Name:
Name of GP:
GP phone number:
GP E-mail:
Is applicant under a CPA?:

If yes please complete details of consultant and CPN.

CPA Level:
Date of Last CPA Meeting:
Date of Next CPA Review:

Kindly send us a copy of the most recent CPA.

Name of Consultant:
Address of Consultant:
Consultant E-mail:
CPN Name:
CPN Phone:
CPN E-mail:

OCCUPATION

Income Status:
Previous Work and Hobbies/ Interests:

PSYCHIATRIC HISTORY

Psychiatric History:
Diagnosis:
Psychiatric Events:
Medication:

OUTCOME FOR PLACEMENT AND SUPPORT NEEDS

Placement Expectations:

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Other Outcomes:
Applicant's Present Mental Condition:
Physical Disabilities:
Audio/Visual or Mobility Issues:
Other Support Needs:

RISK ASSESSMENT

must be completed

Date of Referral:
Date of Risk Assessment:
Date of Discharge from Hospital:
Hospital Admission was::
Agencies Involved:
Previous Services Offered:
Diagnosis / Presenting Problems:
Risk of Violence / Harm to Others:
Risk of Suicide:
Risk of Self-Neglect:
Risk of Severe Self-Neglect / Accident:
Level of Risk:
Risk Management Plan Developed?:
Further Assistance Required:
If yes, detail reason on risk history:

OPTIONAL

you do not need to fill in the following questions if you do not wish to, however we appreciate if you do, as it helps us to ensure that our services reach the widest possible audiences and that they are available to sections of the public that may be underrepresented. This part of the application will be kept separately and anonymously for monitoring purposes only.

Ethnicity:
Ethnicity Sub Category:
Religion or Belief:
Other Religion or Belief:
Sexual Orientation:
Other Sexual Orientation:

FINISH

Thank you for completing this application, we use all information in accordance with the data protection act.
Kindly type your name below to consent to your information being processed by us.

Consent:

Please click here to access our policy about how your personal details will be handled.
You can withdraw your application at any time by emailing services@centreforbetterhealth.org.uk