Support at Home - Referral Form V1

Support at Home Referral Form
Referring organisation*
Name of person making referral*
Email forms to:*
example@example.com
Role title*
Referrers email*
example@example.com
Form completed by if different
Referrers contact number*
Please enter a valid phone number.
Referral source*

A&EWardDischarge LoungeGPCommunitySocial ServicesSelf ReferralFamily/FriendCharityInternal (BRC)Other
Referral source
To be eligible for this service the person must:

NOT have had any infectious diseases still considered to be within a transmissible period e.g. C-diff / CMV / Norovirus
Do you confirm that the person meets the eligibility criteria*

YesNo
Criteria
Consent

NB: we cannot take the referral without consent
Has the person agreed to the referral their personal data being passed to British Red Cross*

YesNo
Personal data
Or if they are unable to consent has a best interest or benefit decision been made

YesNo
benefit decision
If best interest benefit decision name of person making decision
Date of consent Date obtained or of benefit decision*

DayMonthYear
Date
Person's Details
Name*
Gender*
DOB:*

DayMonthYear
Date
Preferred Name
Pronouns
DNAR in place*

YesNoNot Known
DNAR.
Preferred language*
NHS no
Reason for referral
Select all that apply:*

ShoppingTransportPendant alarmKey safeGeneral signpostingOther
Reason for referral
Notes
In relation to supporting this person is there anything that we should be aware of?
Select all that apply.

Drug DependencyViolent BehaviourMental healthAlcohol DependencyBehaviours that challengeLone workingOther
Anything we need to be aware of
Details
Do you have any safeguarding concerns in relation to this referral*

YesNo
Safeguarding
Details

0/255
Communication
Hearing*

FineLimited
Hearing b
Vision*

FineLimited
Vision b
Speech*

FineLimited
Speech b
Details:
Home & Accommodation Details
Address*

Street Address

Street Address Line 2

CityState / Province

Postcode
Mobile
Landline
Is this address temporary*

YesNo
Temp Add
Property type*

HouseBungalowFlatOther
Property type b
Key safe*

YesNo
Key safe b
What is the code
Are they a carer*

YesNo
carer b
Living arrangements*

Living aloneWith spouse/partnerWith other family/friendsNursing/Care homeSheltered accommodationNo fixed abodeOther
Living arr b
Property access issues eg steps lift parking
Pets
Emergency Contact
Name*
Relationship to person*
Consent to contact*

YesNo
Emer contact consent b
Contact number*
Hospital Referrals

(Please leave blank if you are not referring from a hospital setting)
Reason for admission attendance
Date of admission attendance

DayMonthYear
Date
Date of discharge

DayMonthYear
Date
Will the referral contribute to any of the following? (Select all that apply – to be completed by referrer)

Quicker dischargeSafer dischargePrevent a hospital admissionReduce length of stayPrevent a delayed transfer of careHelp prevent breach of the 4-hour standard of A&E
Medical & Health
Is this person on a Virtual Ward*

YesNo
Virtual ward b
History of falls*

YesNo
Falls b
Do they smoke*

YesNo
Smoke b
Any known allergies*

YesNo
allergies b
Medical conditions*

YesNo
Medical b
Provide details*
GP Surgery name
GP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Phone Number
Please enter a valid phone number.
Care Arrangements & Other Services
Is there a care package in place?*

YesNo
Care package b
Details of care package frequency etc
Contact number
Name of provider
Other services engaged with the person
Additional notes from referrer:
3 Park Plaza, Battlefield, SY1 3AF

01743 457810

http://www.redcross.org.uk/
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Support at Home Referral Form

To be eligible for this service the person must:

Consent

Person's Details

Reason for referral

In relation to supporting this person is there anything that we should be aware of?

Communication

Home & Accommodation Details

Emergency Contact

Hospital Referrals

Medical & Health

Care Arrangements & Other Services