Referrer's Full Name
*
First Name
Last Name
Referrer's Email
*
Referrer's Phone Number
*
(###)
###
####
Permission to Refer
*
You will need to obtain consent in writing from the client for your own records and provide us with copies when we work on-site.
Permission to share outcome
*
When you obtain consent to refer the client you will also need to have obtained permission for us to share the outcome of our work with you.
Fitness to recieve information, advice or guidance
*
Please confirm that when you last spoke to this client they appeared well enough to understand information, advice or guidance. We understand conditions can fluctuate but it is important this assessment is made.
Client's Full Name
*
First Name
Last Name
Client's Date of Birth
*
MM
DD
YYYY
Client's Email
Client's Phone Number
(###)
###
####
Client's Preferred Method of Contact (post-discharge))
*
We will see the client on site at St Charles Hospital in the first instance but need to know their preferences for future contact.
Consent to Record Special Category Data
*
The client gives express permission to record and share special category data with Citizens Advice Kensington and Chelsea for the following:
What date was the client admitted onto the mental health unit?
This helps us to understand how their benefits or housing may have been affected by the duration of their stay.
MM
DD
YYYY
What date is the client likely to be discharged from the mental health unit?
This helps us to understand the urgency of their issues ahead of returning to the community.
MM
DD
YYYY
Briefly summarise any accessibility challenges that we should be aware of before meeting the client?
For example, if the client experiences psychosis it may be helpful for our adviser to know that the client may express a different perception of reality than we know to be true.
Does the client have access to the internet?
*
Yes
No
Don't know
Is the client confident about using the internet to read and understand information?
*
Yes
No
Don't know
Is the client confident in filling out forms, reading and writing?
*
Yes
No
Don't know
Does the client need help with communication or interpretation?
*
Yes (the client cannot speak / understand any English)
Yes (the client can speak / understand some English)
No (the client can speak / understand English with no issue)
Don't know
Does the client have a preferred language (other than English)?
If there are any known risk factors with this client, please tell us here:
Has the client contacted Citizens Advice or anyone else about this issue(s) before?
*
Yes
No
Don't know
What category does this issue(s) fall within?
*
If the matter is urgent then please provide the deadline that we need to know about:
MM
DD
YYYY
Issue 1
*
Issue 2 (if applicable)
Issue 3 (if applicable)
HOUSING: Type of accomodation
[Select Option]
Private Tenant
Owner-occupier
Council house
Housing association
Temporary housing
Homeless
Other
HOUSING: Cost of accommodation (per month)
HOUSING: Number of bedrooms in the home
[Select Option]
1
2
3
4
5+
HOUSING: Is the client at risk of homelessness?
[Select Option]
Yes
No
HOUSING: Who lives in the client's home? What are their ages and what are their relationships to the client?
HEALTH: Does the client have any health conditions relevant to this referral, and if so what are they?
HEALTH: Does anyone in the client's household have any health condition relevant to this query, and if so what are they?
NATIONALITY / RIGHT TO RESIDE: What is the client's nationality?
NATIONALITY / RIGHT TO RESIDE: What is the client's right to live in the UK?
[Select Option]
British Citizen
Indefinite Leave to Remain / Settled Status
Visitor's Visa
Worker's Visa
Student Visa
Family Visa
Pre-settled Status
Sponsored Visa
Other
INCOME: What benefits does the client claim? (amount and frequency)
INCOME: What wage does the client earn? (amount and frequency)
INCOME: Does the client need a benefit check?
[Select Option]
Yes
No
DEBT: Does the client have any debts? If so, how much and who do they owe it to?
EMPLOYMENT: What is the client's employment status?
[Select Option]
Full time (Employed)
Part time (Employed)
Zero hours contract (Employed)
Full time (Self-Employed)
Part time (Self-Employed)
Consultant (Contractor)
Unemployed
EMPLOYMENT: Contract type
[Select Option]
Permanent
Fixed term
Zero Hours
Agency worker
Not applicable
EMPLOYMENT: (If applicable) How long has the employer worked for their employer?
