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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:

Which trainee placement is the applicant interested in?:

How did you hear about us?:

TRAINEE DETAILS



Date of Birth (please enter as dd/mm/yyyy):
Gender:
Gender - self description:




Current Address


Borough:

MAIN SUPPORT FOR TRAINEE

If you are making this referral on behalf of the applicant please enter your details below

First Name:
Last Name:
Which organisation and department do you work for?
Address:
What is your role in relation to the applicant?
Phone:
Email:
We require a primary contact for this applicant, if different from above, please indicate contact details here:
First Name:
Last Name:
Role in Relation to Applicant:
Phone:
E-mail:
Work Address:

We also require GP details. Please give details below.

GP Name:
Surgery:

OCCUPATION

What is the applicant's employment status:
Please provide any details of applicant's work history:

PSYCHIATRIC HISTORY

Please give a summary of the applicant's psychiatric history, hospital admissions, and dates and forms of admissions and discharges. Please also describe the applicant's current mental health. If the applicant was ever hospitalised,was the admission voluntary or on section?

Has the applicant ever been diagnosed with a mental illness?:
If yes, what was the diagnosis?:
Is there any record of delinquency, suicidal depression, alcohol or drug abuse or addiction?:
Is the applicant currently on medication?:
If yes, provide details:

Is the applicant under a CPA*?:
*If you indicated yes, we may email the primary contact to obtain a copy of the CPA

OUTCOME FOR PLACEMENT AND SUPPORT NEEDS

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

Please indicate either yes or no for each option:
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 any disability, audio or visual impairment, mobility issues or any other support needs?
If yes, please give details:

RISK ASSESSMENT

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:
Please provide details of any risks:

Level of Risk:
Has a risk management plan been developed?:
If a management plan is in place, please give details here:


If Level of risk 3 or 4 is selected, please complete sections A,B,C and D
A. Clinical Symptoms

Early Signs of Relapse:
Ideas of Harming Others:
Ideas of Self-Harm:
Suicidal Ideation:
Delusion or Hallucination:
Lack of Control / Impulsivity:
Other Clinical Symptoms:

B. Behaviour

Physical Harm to others including threats / Intimidation:
Physical Self-Harm and/or suicidal attempts:
Self-Neglect:
Domestic Risk (family, unsafe use of appliances, fire risk etc...):
Arson:
Drugs / Alcohol Abuse:
Other Behaviour Risks:


C. Personal Circumstances

Recent Severe Stress:
Abusive / Victimisation of Others:
Inadequate/No Accomodation:
Concerns by Others:
Known Personal Trigger Factors:
Social Isolation:

D. Forensic History

Conviction : violence or sexual offences:
Special hospital / unit / hostel or medium secure unit:
Other forensic involvements (i.e. arson, injunction, shoplifting):

APPLICANT'S AVAILABILITY

Placements are 1 day per week from 10am to 4pm

Which day(s) is the applicant available?


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 :
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 confirm that you have the applicant's consent to fill in this form.

Consent:

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