Please forward all requests to:    'CREATE', Cwmbwrla Day Centre, Heol-y-Gors, Cwmbwrla, Swansea, SA5 8LD

C.P.A. Status

Standard:

Enhanced:

Service Eligibility: If not assessed as appropriate for C.P.A., have the Service User's Needs been assessed against Social Services Eligibility Criteria?
Yes No

Name of assessing Social Worker

N.B, - Areas highlighted red must be completed - if not completed, request will be returned

SURNAME:  FORENAMES:

Title:  Select One Dr Mr Mrs Ms Miss      Marital Status: Select One Married Single Widowed Divorced Seperated

Address:

Post Code: Tel No: Mobile No:

Date of birth: N.I. NUMBER:

Religion: Ethnic Origin:

Service Requested By: Care Manager:

Address:

Post Code: TEL No: Date of Request:

Service User Informed & in agreement with Request YES / NO
Does Service User Agree To Information being shared with other agencies, in relation to this Request ? YES / NO If YES, are there any agencies with whom the service user does not wish information to be shared?

Name of G.P.: Practice:

Address:

Post Code: Tel:

Other Agencies/Workers Involved.

Consultant:

Statutory Sector:

Next of kin: Relationship to client:

Address:

Post Code: Tel No:

Main Carer (if different): Relationship to client:

Address:

Post Code:   Tel No:

Benefit Situation (Tick As Appropriate)

D.L.A. Care   L M H   D.L.A. Mobility   L H

Income Support    Incapacity Benefit    Housing Benefit

Other information.
Full Current Driving Licence? Yes No   Able To Use Public Transport? Yes No

Please indicate if the individual has difficulties with:-    LITERACY    NUMERACY

REASON FOR REQUEST : (N.B. A current care plan + risk assessment must be included with this request)

PSYCHIATRIC HISTORY : (N.B. A current care plan + risk assessment must be included with this request)

MEDICATION:

PHYSICAL HEALTH: (Please describe any physical health problems or concerns)

ADDITIONAL INFORMATION (Please Indicate e.g.;- Gender Preferences, First Language)

For CREATE use only:

RECEIVED BY: DATE RECEIVED:

DATE ALLOCATED: ALLOCATED TO: