Mental Health Service Provision Request Form

COMMUNITY REHABITLITATION, EMPLOYMENT,
ASSESSMENT & TRAINING ENTERPRISE

DAY SERVICES REQUEST FORM.

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: Dr / Mr / Mrs / Ms / Miss Marital Status: M / S / W / D / Sep

Address:.......................................................................................................................................................................................................................

.........................................................................................................................................................................................................................................

Post Code: ............................................ Tel No: .............................................................. Mobile No:....................................................................

Date of birth:........../........./......... N.I. NUMBER:......../......../......../......../........

Religion:........................................................................................... Ethnic Origin: .................................................................................................

Service Requested By: ................................................................................ Care Manager:.............................................................................

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:..................................................................................................

.................................................................................................... Post Code:................................... Tel: ....................................................................

Other Agencies/Workers Involved.

Consultant:........................................................................................... Statutory Sector:........................................................................................

Next of kin: ....................................................................................... Relationship to client: ..................................................................................

.......................................................................................................... Post Code: ................................ Tel No: ..........................................................

Main Carer (if different): ............................................................ Relationship to client: ......................................................................................

................................................................................. Post Code: ..................................... Tel No: ...........................................................................

Risk Issues:

Benefit Situation (Tick As Appropriate)

D.L.A. Care L M H Income Support Incapacity Benefit Housing Benefit
D.L.A. Mobility L H

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: ..........................................................................