The Support Centre

Office use only Date Received:

Acknowledged by: Assessment Date: SIKH ELDERS Key Worker: SERVICE PSOCC No: Referral Form

Please complete all sections of the referral form. Incomplete forms will be returned for further information. Also, please ask the person you are referring to complete and sign the consent form at the end of this Referral Form to enable us to complete the assessment with minimum delay. Surname: Title: Mr / Mrs / Miss / Ms

Forename(s): Date of Birth: Age:

Address: Telephone No:

Postcode: Mobile: Referrer - Name: Date of referral: Job Title: Organisation/Relationship: Address:

Postcode: Telephone: Email address: Preferred arrangements for contacting client by:

Telephone □ Mobile □ Letter □ Punjabi □ English □

Occupation: please tick all that apply

Retired □ Employed □ Carer □ Long Term Sick □ Other □

Relationship status

Married □ Widowed □ Separated □ Divorced □ Single □ Not Known □ Gender Female Male

At birth were you described as (please tick one option)

Male Female Intersex Prefer not to say

Which of the following describes how you think of yourself (please tick one option) Male Female In another way

Sexual Orientation: please tick all that apply

Bisexual □ Gay □ Heterosexual □ Lesbian □

Prefer not to say □

Ethnicity: please tick all that apply

Indian Bangladeshi Pakistani Kashmiri

Asian British White/Asian Mixed Other Other

Religious Atheist/Agnostic/None Buddhist Belief/ Sikh Confucian Faith Hindu Jewish Muslim Rastafarian Other (please Prefer not to say specify)______Christian Taoist

Preferred language: please tick all that apply English Punjabi Hindi Urdu Other(Please specify):

2 Others involved in the client’s care at present:

Family □ Other □ GP □ Social Worker □ Occupational Therapist □ Hospital □ Community & Religious Involvement □

Current Housing Status 

Homeowner □ Rented □ Living with family/friends □ Lives on their own □ Housing Support □

Other (Please Specify): …………………………………………………………………………….

Please list any health issues you have:

Diabetes □ Heart Disease □ Stroke □ Arthritis □

Blood Pressure □ Dementia □ Depression □ Speech impaired □

Vision impaired □ Hearing impaired □ Learning difficulty □

Please list any other:……………………………………………………......

…………………......

……………………………………………………………………………………………………………… …

3 Do you have mobility issues:

No □ Limited mobility □ Wheelchair user □

4 CLIENT SERVICE REQUEST: please tick all that apply Support needs  Description:

Befriending Sharing a meal with a volunteer

Aids & Adaptation

Welfare Check eg: Benefits

Form filling/letters & Advocacy

Social & Leisure Activities E.g. Exercise Healthy Eating Daytime social group Evening social group Trips/Outings Other Education/Training  Computer  ESOL Classes Counselling eg: Bereavement & Anxiety Housing & Home security

Fire Service

Police Service

Alternative Therapy

Home Support Respite Personal Care Domestic Sitting Service

Access Bus

5 Any other information that may assist your application:

How did you find out about the Sikh Elders Service?......

Please return this form to:

Sikh Elders Service Tel: 0113 216 3143 Touchstone Support Centre 53-55 Harehills Avenue Leeds, LS8 4 EX Fax: 0113 216 3140

6 CONSENT FORM

To enable us to help you, we may need to speak to others involved in your care and support. We would be grateful if you would complete and sign this form authorising us to discuss your care needs with other organisations.

AUTHORITY TO DISCLOSE INFORMATION

I hereby give my consent for Sikh Elders Service to gather and share information about me and my support needs with other agencies and relevant people who know me.

First name:

Last name:

Address:

Signature: …………………………….……………..

Date: …………………………………………………………………………………………………………..……………………………………………..