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.

Please select which enterprise the applicant is interested in:

Bakery:
Bike Shop:
Light Industrial Unit:
How did you hear about us?:

TRAINEE DETAILS





Borough:

Is this applicant's home address?:


Is it ok to leave a message?:

Date of Birth:
Gender:
Gender - self description:

MAIN SUPPORT FOR TRAINEE

Please enter the details of the referrer:

Referrer First Name:
Referrer Last Name:
Organisation and Department:
Role in relation to applicant:
Referrer Phone:
Referrer Address:

We require the details of a person to contact in case of emergency as well as GP details. Please give details below.

Emergency Contact:

Name:
Role in relation to applicant:
Phone Number:
Email:
Address:

GP/Surgery details

Name:
Surgery:
Phone Number:
E-mail:

OCCUPATION

Please select the applicant's employment status:
Please provide details of applicant's work history, hobbies and interests:

PSYCHIATRIC HISTORY

Please give a summary of the applicant's psychiatric history, hospital admissions, and dates and forms of admissions and discharges:
Is there any record of delinquency, suicidal depression, alcohol or drug abuse or addiction?:

Is applicant under a CPA?:

Has the applicant ever been admitted to the hospital experiencing mental distress?:
If yes, please provide details including such things as hospital, date/s, length of stay and issue/s at the time:

Has the applicant ever been diagnosed with a mental illness?:
If yes, what was the diagnosis?:

Has the applicant ever been prescribed medication for mental health issues?:
If yes, please provide details:

Is the applicant currently on medication?:
If yes, please provide details:
Please provide a description of the applicant's current mental health:

OUTCOME FOR PLACEMENT AND SUPPORT NEEDS

What is the applicant looking to get out of the placement?


Job skills:
Motivation:
Increase Stability / Develop Routine:
Improve Confidence:
Social Skills:

If the applicant has any further placement expectations, please provide details:
Does the applicant consider themselves to have a physical disability?:
Does the applicant consider themselves to have audio/visual or mobility issues:
Please provide details of any further support needs:

RISK ASSESSMENT

Please note this section is compulsory

Please select whether there are any risks:

Risk of Violence / Harm to Others:
Risk of Suicide:
Risk of Self-Neglect:
Risk of Severe Self-Neglect / Accident:
Level of Risk:

Please provide details of any risks:
Has a risk management plan been developed?:
Is further assistance required?:
Date of Risk Assessment:

Date of Discharge from Hospital:
Please select whether the hospital admission was voluntary or on section:
Please list any agencies involved:
Please provide details of any previous services offered:
Please provide details of any previous services refused:
Please provide deatils of diagnosis/presenting problems:

APPLICANT'S AVAILABILITY

Please select when the applicant is available:

Daytime Monday:
Daytime Tuesday:
Daytime Wednesday:
Daytime Thursday:
Daytime Friday:

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 acknowledge that you have consent to fill in this form.

Consent:

Please click here to access our policy about how personal details will be handled.