Application and Assessment Form

Initial Contact Date

Client Contact Details

Full Name

Date of Birth Age (18-25) (26-35)(36-45) Gender Male / Female/ Transgendered (46-55)(56+)

Telephone Number (Home/Mobile)

Address

Ethnic origin : (please circle) BME Yes/No (a) White (b)Mixed (c) Asian or Asian British  British  White and Black Caribbean  Indian  Irish  White and Black African  Pakistani  Any other white  White and Asian  Bangladeshi background  Any other mixed  Any other Asian background background

(d) Black or Black British (e) Chinese or other ethnic  Caribbean group  African  Chinese  Any other black background  Other/Arab  Any other

If you are a self-referral please let us know if you are accessing any other mental health services. This is so we can ensure that you are receiving the support you need. If you would like to find out about mental health support services in Westminster please ask.

Names of other mental health services that I am currently accessing:

Referred by Engaged with project

Benefits that I am receiving: Referred By

Self Care co-ordinator If someone else please fill in referrers contact details below

If the volunteer is referred by someone else please give the referrers contact details

Full Name

Position / Job Title

Organisation

In what capacity do you know the potential volunteer?

Telephone

Address

Are you currently on a CPA Yes/No If Yes is it a standard or standard/ enhanced CPA enhanced If you have a Care Coordinator, please let us know their contact details below.

In order to make sure that you are supported in the best possible way, it might sometimes be necessary for us to ask your Care Coordinator for support. These details are also important as an emergency contact, for example if you become unwell or we have not been able to contact you for some time.

Do you consent to us contacting your care-co-ordinator Yes/No

Are you currently on a CPA Yes/No If Yes is it a standard or standard/ enhanced CPA enhanced Do you consent to us asking your care-co-ordinator for a copy of your CPA Yes/No

Do you consent to us asking your care-co-ordinator for a copy of your Risk Yes/No Assessment

Care Coordinator Full Name

Organisation, e.g. Community Mental Health Team or Day Centre Contact Telephone

Address If you are a Self-Referral and do not have a Care Coordinator, please let us know the contact details of another person who has known you for over a year and can provide you with a reference.

Person’s Full Name

Post/Relationship to volunteer

How long have you known the volunteer

Organisation

Contact Telephone

Address

Date Reference requested/contacted: Reference received: YES NO

Request for Volunteer Reference Date Reference requested/contacted: Reference received: Why do you want to volunteer?

Enjoyment To help find paid work

Other:

Have you worked or volunteered before? If you have could you please tell us about what you did (with approximate dates if possible).

What is your current routine/how do you spend your day? Volunteering means that you are making an agreement to volunteer at a certain time each week or month. How confident do you feel about having to be reliable and punctual?

Not very confident Very confident

If you feel that being punctual and reliable might be difficult, what support do you feel would make this easier for you?

Volunteering will probably mean that you will need to go to a new place and meet new people. Please indicate how you feel about the statements below by ticking the appropriate box.

Not very Sometimes Very confident Not sure confident confident Being in a new place Asking for help Understanding new tasks Meeting new people Talking to people on the telephone

If you are concerned about any of the above, what support do you feel might make this easier for you?

In every volunteering placement, you will take in new information about other volunteers, staff, the organisation and the tasks you will be doing as a volunteer. Please tell us how confident you feel about the following statements by ticking the appropriate boxes.

Not very Sometimes Very Not sure confident confident confident Taking in new information Reading, e.g. instructions Writing, e.g. letters Using computers, e.g. word processing, email, excel Using the telephone Basic Numeracy Understanding instructions in English If you are concerned about any of the above, what support do you feel might make this easier for you?

Are you currently attending any courses or training?

Would you like to find out about any courses or training to help you to volunteer?

Yes English Using computers, e.g. word processing, email, excel Basic Numeracy Understanding instructions in English Other

If you would like to volunteer in a role that involves working with children or vulnerable adults (this includes people with a physical disability, people who have mental health issues, people on probation, elderly people etc.) organisations have to carry out enhanced Criminal Record Bureau checks. These checks will inform the organisations of any convictions a person might have had, even if these might be regarded as spent in other situations because they were a long time ago. Having previous convictions does not exclude you from volunteering but being honest about any convictions will help us to advice you best about which opportunities might be open to you.

If you have had a conviction, please let us know what kind of conviction and how long ago it was received. Volunteering might mean using public transport and finding new places. Please let us know how confident you feel about the following statements by ticking the appropriate box. 5.

Not very Sometimes Very Not sure confident confident confident Finding new places Planning a journey Using the bus Using the tube Using the train

We can offer you some support with travelling? Please let us know what support you would like by ticking the boxes

Planning my travel route with me Travelling with me to the organisation for the first time

Is there any volunteering roles or activities that particularly interest you? Below are some examples of volunteering opportunities. Please tick the box next to the roles or activities that interest you or add your own below.

Working with animals Working with computers Gardening Supporting the homeless Working with children Supporting people with disabilities Working with the elderly Supporting Training/ Teaching Working in charity shops Advice Work General office admin Translation Befriending another person Cooking or catering Work experience

Other ______

Please name 3 things that do you think you are good at?

Please name 3 things that do you think you need help to improve on? Are there any volunteering roles or activities that you would not like to do or you would feel anxious or uncomfortable about?

On a scale of 1 – 10 how would you describe your mental health over the past year?

On a scale of 1 – 10 how would you describe your mental health now?

More information

What are the signs that you are becoming unwell?

Are you currently taking medication? If you are how does it affect you? Is there any further information you would like us to know about and consider when arranging a volunteer placement for you? This could include things around your mental health and how this might affect your volunteering, or particular support needs around physical disabilities, health conditions or learning needs.

What days are you available Mon Tue Wed Thurs Fri Sat Sun to volunteer? am pm am pm am pm am pm am pm

Action plan from first session:

Declaration

If Referred: For the referrer I understand that Support4Volunteering will use the information I have provided on this form to help the potential volunteer access and undertake suitable volunteering. The information provided here is accurate to the best of my knowledge. I have worked with the volunteer to complete this form and have read the information provided on this form.

Signature Date If Self-Referred: For the potential volunteer I understand that Support4Volunteering will use the information on this form to help in finding a suitable volunteering placement and that Support4Volunteering will treat this information confidentially.

Please tick the appropriate box for the following statements.

I give permission to Support4Volunteering to disclose information about my mental health to potential volunteer placement organisations. I understand that such information will only be disclosed if deemed necessary by the project worker and, except in an emergency, after discussion with me.

I give permission for my Care Coordinator and/ or referrer to discuss details about my mental health with the project worker at Support4Volunteering. I understand that this will only happen if the project worker needs to seek advice about my choice of voluntary placement or has concerns about my health.

Signature Date

Please return this form to Sam Tallant or Trecina Rajakone Support4Volunteering The Basement Hopkinson House 6 Osbert Street London SW1P 2QU