START

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 area are you 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

Referrer First Name:
Referrer Last Name:
Which organisation and department do you work for?
What is your role in relation to the applicant?
Referrer Phone:
Referrer Email:
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:
What is their role in relation to the applicant?
Phone Number:
Email:
Address:

GP/Surgery details

GP Name:
Surgery:

OCCUPATION

What is 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 diagnosed with a mental illness?:
If yes, what was the diagnosis?:

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

Is the applicant currently on medication?:
If yes, 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?

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?
If yes, please give details:
Does the applicant have any audio or visual impairment or mobility issues?
If yes, please give details:
Does the applicant have any other support needs?
If yes, please give details:

RISK ASSESSMENT

This application will not submit without this information

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:
If Level 3 or 4 is selected, please complete sections A,B,C,D and E

Please provide details of any risks:
Has a risk management plan been developed?:
Is further assistance required?:
Date of Risk Assessment (please enter as dd/mm/yyyy):

Date of Discharge from Hospital (please enter as dd/mm/yyyy):
Was the hospital admission voluntary or on section?
What were the agencies involved?
Please provide details of any previous services offered:
And details of any previous services refused if applicable:
Please provide details of diagnosis/presenting problems:

The following sections are to be completed when Level 3 or 4 were scored as current level of risk
A. Clinical Symptoms

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

B. Behaviour

Physical Harm to Others:
Threats / Intimidation:
Physical Self-Harm:
Suicide Attempts:
Self-Neglect:
Domestic Risk:
Arson:
Drugs / Alcohol Abuse:
Other Behaviour Risks:

C. Treatment

Discontinuation of Medication:
Failure to Keep Appointments:
Compulsory Admissions:
Supervised Discharge:
Restriction Order:
Conditional Discharge:

D. Personal Circumstances

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

E. Forensic History

Conviction : Violence or Sexual Offences:
Special Hospital / Unit / Hostel:
Medium Secure Unit:
Other Forensic Involvements (i.e. arson, injunction, shoplifting):

APPLICANT'S AVAILABILITY

Which day(s) is the applicant available?

Monday:
Tuesday:
Wednesday:
Thursday:

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.