Let’s Work Together Referral Form

(Please complete in black pen and capitals)

Title First Name Surname Date of Birth Male/Female

Address If required provide alternative contact details: Name:

Tel No:

Post Code Relationship to person being referred:

Tel No: Communication needs e.g. interpreter required

Referrals Direct to Organisation Referral ALCOHOL Contact ADSIS Agreed Tel : 08445-617079 DEMENTIA SUPPORT Contact Homestead Dementia DEBT Contact Support Team Illegal Money Lending Team 0300 555222 Telephone Number: 01283 539917 [email protected] [email protected] Budget Management Contact East WEIGHT MANAGEMENT Contact Waistlines Citizens Advice Bureau 01283 527985 or email Adult Weight Management Service on 01543 509740 [email protected] (Central Booking Hub). Fuel Poverty contact East Staffordshire ISOLATION Contact Jane Ingram at Age UK Burton Council 01283 508483 or email

Tel: 01283 510106 [email protected] [email protected] CARER SUPPORT Contact Carers Association South FALLS Contact the Falls Team East Staffordshire Staffordshire Telephone: 01785-606675 or e-mail Telephone Number: 01283 507206 [email protected] Fax Number: 01283 749222

SMOKING Contact The Stop Smoking Service Referrals via Patchwork application Tel: 03452-450759 MEDICINE MANAGEMENT: check label on dispensed HOUSE REPAIRS/ENERGY Contact East Staffordshire medicine and contact pharmacy. If not possible log onto Borough Council www.nhs.uk/servicedirectories and contact pharmacy Tel :01283 508836 / 01283 508845 / 01283 508846 or near client e-mail [email protected] DOMESTIC VIOLENCE Contact HOUSING OPTION (Threat of homelessness)Contact Kiaura 01283 569598 (which covers floating support, East Staffordshire Borough Council Tel : 01283 508120 refuge and IDVAs) or e-mail [email protected]

SAFEGUARDING (ADULTS AND CHILDREN) Contact FIRE Contact Staffordshire Fire and Rescue Service

Staffordshire Services Social Care and Health: Tel : 0800-0241999 or e-mail 0845-6042719 [email protected]

Children and Families First Response: 08001-313126 ASB/FEAR OF CRIME contact Police Hours: Monday – Thursday 08:30 17:00, Friday 0830 – 1630 Tel : 101 or e-mail Emergency Duty 24 Hour Number: Children and Adults: [email protected] 08456-042886 Additional Comments relating to the referral: e.g. interpreter required, accompanied visit required, male/female only

Information Sharing Agreement Please ensure you have consent signed for by client or authorised person e.g. carer (Please ensure boxes are ticked as appropriate) I agree to be contacted directly by the agencies I have agreed to as listed above and for information collected on this form to be shared with them. I agree for my information to be added to the patchwork system which could be seen by designated and authorised people working for all of the above organisations.

Print Name …..………………………….………………………………………Signed …………………………………..…………………………… Date ………………………………………………………….. Signature on behalf of Service User (if applicable)

Print Name ………………………………………………………….………… Signed …………………………………………..…..….………… Date ………………………..…………………………….. Form Completed by

Name: …………………………………………………………………………… Signature: ……………………………………………..……………………………

Referring Organisation e.g. PCT/SCH/FARS etc: ………………………………………………….……………………………… Tel ……………………..……………………………………………..

Please tick when referral has been made Date of Referral: …………………………………………....……..

Data Protection – This information will be used for monitoring purposes it will not be disclosed to any third party unless specifically agreed by you. All personal information held is maintained in accordance with the data protection act 1998. Access to the information will be restricted when completed and will be treated as PRIVATE – PERSONAL

Please send completed forms to: Ranbir Sahota, LWT Project Manager, ESBC, PO BOX 8045, , Staffordshire, DE14 9JG. Contact details: [email protected] Tel: 01283 508625 Fax: 01283 535412