SUPPORTED LIVING REFERRAL FORM

Referrals to Akerman Care Limited are to be completed by the most appropriate professional, such as a Social Worker, CPN or Care Coordinator etc. In support of this referral, please enclose relevant health and social records and risk assessments along with the most recent local authority support plan.

Akerman Care Limited Referral Criteria

Akerman Care Limited provides supported accommodation to vulnerable adult’s aged 18 and over.

Akerman Care Limited provides accommodation and person-centred packages of care and support for adults with range of diagnoses including autism, learning disabilities and mental health conditions.

All our current properties have stairs so prospective service users will need to be mobile, although please enquire for those with mobility issues as there is limited provision on the ground floor.

We are committed to supporting individuals in creating meaningful and fulfilling lives.

We welcome people with long and enduring mental illness with complex needs who would benefit from our support to enhance their confidence, self-esteem and activities of daily living skills.

We support referrals from a range of people with mental health needs. We actively support their emotional health and wellbeing and their chosen recovery journey by helping them to continually engage in their care and treatment programme.

We will support people who misuse alcohol and enable to seek support with their alcohol usage by accessing local alcohol services, (but they will not be permitted to drink alcohol on the premises).

Anyone referred to Akerman Care Limited would need to participate in the creation of their support plan and ensure they claim their entitlement to housing benefit.

Referral Form – Guidance Note for the Referring Agency

This form is to be used for all agency referrals for supported living.

It is the responsibility of the referring person to ensure the completion and submission of this application and that the information contained is truthful and accurate.

Health / Social Care: Those without exempt housing status who have a Care Coordinator and are part of the Care Programme Approach (CPA) or are entitled to 117 Aftercare Funding need to discuss one to one supported hours needs with Akerman Care Limited before a placement can be confirmed as funding needs to be in place prior to the placement commencing.

Risk section: You should include only “actual known risks”

Answers to all questions should be given including N/A if not applicable, N/K if not known or N/D if applicant would not disclose. THERE SHOULD BE NO BLANK BOXES.

Referring agents are asked to identify any on-going support / action which may be required.

The Referral Process

Referring person/authority complete the form with the agreement and involvement of the applicant.

Akerman Care Limited will complete internal checks to determine if the person being referred is suitable for our service. A comprehensive assessment will be undertaken and the decision shared in writing.

The referred person, if successful, will be offered an assessment, again if successful / unsuccessful the referring person will be informed of the outcome and the reason for the decision made.

A decision not to offer supported living at the time of referral does not prevent a further application being made at a later stage, should the person referred meet the requirement of Akerman Care Limited, and a suitable vacancy becomes available.

If the person being referred is successful, a package of support will be agreed with the service user and referring person/authority before the commencement of their tenancy.

Referral Form

Akerman Care Limited provides supported accommodation for single room occupancy in Filton, Bristol. Prospective tenants must be for aged 18 or over.

All information provided on this form will be stored confidentially. Please disclose as much information as you can, so that we can consider the referral without delay.

Section 1: Basic Information

Date of referral
Date Supported Living Required
Urgency

Proposed package of care
Financial: What funding and support is available to the person being referred? Such as: 117 Aftercare provision

Referred by
Designation
Correspondence address
Telephone No

Name of service user
Date of birth
Gender
Next of kin?
National insurance number
NHS number
Current address
5. Most recent GP (Name, address and contact number)

Pen Picture

Diagnoses / Problems
Autism Spectrum Disorder:	Learning disability:
Mental health condition(s):	Alcohol and/or substance misuse:
Antisocial behaviour including damage to property:	Violence:
Other:

Section 2: Reason for Referral

What is their current housing situation? Reasons for seeking supported living?
Required placement profile:

Describe how they cope with the following areas:
Paying rent:	Keeping appointments:
Cleaning:	Cooking:
Living with others:	Managing benefits:

Goals: Future goals?
Believe: What do they believe they can achieve with this opportunity?
Aspire: What are their aspirations?

Section 3: Health and social care needs

Professional Support Network: Please give details of any other agencies or supportive organisations involved, including names and contact details
Name
Designation
Telephone number
Email

Name
Designation
Telephone number
Email

Mental health needs:
Please list diagnosis and medications prescribed:
Is the person entitled to section 117 aftercare?

Mental Capacity:
Is the person lacking capacity?	supply further information including frequency, triggers, last episode
Is there is recent mental capacity assessment?	supply further information including frequency, triggers, last episode
If so, would the person require a DoLS	supply further information including frequency, triggers, last episode

Prescription medication? Please provide full list of all medications
Medication:	Dosage	Frequency	Reason

Section: 4 Risk Profile

Criminal convictions? Please list ALL convictions with dates:
Have they ever been under any form of supervision? Please tick relevant box: [ ] Probation [ ] Suspended sentence [ ] Supervision order [ ] Parole [ ] Care order [ ] Care programme
Are they in custody? Please give details: Release date:
Applicant Statement:
For the reason, they need supported housing:

Suicide:
Suicidal ideation	supply further information including frequency, triggers, last episode
Attempts to end life?	supply further information including frequency, triggers, last episode
Significant dates that can trigger relapse in mental state.	supply further information including frequency, triggers, last episode

Self-Harm:
Have they ever intentionally self-harmed?	supply further information including frequency, triggers, last episode
How do they self-harm?	supply further information including frequency, triggers, last episode
Self-harming method?	supply further information including frequency, triggers, last episode
Self-harming Triggers?	supply further information including frequency, last episode
Has this led to hospitalisation?	supply further information including frequency, triggers, last episode
Date of Last Episode:	supply further information including frequency, triggers, last episode

Risk Assessment
Please state how long you have known/worked with the applicant.
What capacity have you known the applicant?
Please provide details of any restrictions or orders placed on the person? Such as Community Treatment Order (CTO), S37/41 Ministry of Justice. (MOJ).
Are they open to secondary mental health services and please give information on past assessments/treatments and history to include length involvement and any Hospital admissions?

Please provide a brief risk assessment and rating in respect of risk posed to self/others:
Low	Medium	High
Explanation:

Section 5: Supporting records and information

Please list all documents and reports shared in support of this referral. Such as, copies of risk assessments and care plans.

By signing and/or submitting this form you agree that you have provided accurate and full information. Note that Akerman Care Limited will not be able to proceed with the offer of an assessment if the information enclosed is insufficient or unsatisfactory.

We rely on the information shared as part of this referral when formulating a needs assessment and therefore please ensure all records of relevance are enclosed and/or referenced.

Signed service user : Signed Referring person: Name: Job Title: Tel: Email: Date:

Please add any additional information here and email securely to xxxxx