<p> Support & Wellbeing Information Service Harrow (SWiSH) Referral Form</p><p>Eligibility Checklist Ordinarily resident of Harrow 18 years or over</p><p>Client Contact & Personal Details Full Name Title Address Postcode Landline Mobile Date of birth Male Female Email</p><p>Access Needs Interpreter needed Language(s): Disability access needs </p><p>What information or advice is needed</p><p>Client Needs Autistic spectrum Mental health Carer Older person (60 years old +) Dementia Physical disability Learning disability Sensory impairment</p><p>Response time requested Crisis Urgent Non-urgent (today) (Next day) (3-5 working days)</p><p>Type of service requested Phone Email Face-to-face</p><p>Client Risk Assessment High risk Medium risk Low risk Please provide details - Medium to High risk</p><p>Referrer – Contact Details</p><p>Staff name Agency Phone Email Client consent given to share this information</p><p>How to use this form is explained on page 2.</p><p>FOR OFFICE USE: Referral ID number 1 About the Support & Wellbeing Information Service Harrow (SWiSH) Harrow Community Action (HCA) consortium is providing this service with 5 local charities: Age UK Harrow, HAD, Harrow Carers, Harrow Mencap and Mind in Harrow. This service has been commissioned by Harrow Council to provide a local Care Act 2014 Information & Advice Service. </p><p>Who our service is for  For anyone in Harrow 18 years and over who wants information or advice about local support services for and ways to keep safe and well.  As well as people looking for help for themselves, the service is open to carers and staff in local organisations.</p><p>What the service offers We can offer information or advice about a wide range of local services, including: where to go to keep fit and well, manage finances, join social groups, look for work, start a course, access help with housing or welfare benefits or apply for a personal budget.</p><p>Our service does not offer financial advice, legal advice, advocacy 1:1 case support for welfare benefits and housing, but we can provide information about where to find this help. Please contact our service to find out more.</p><p>How to use the referral form Please ensure the ‘Client consent given to share this information’ box is ticked before sending to the service. Thank you.</p><p>For referrals as a general enquiry, please send the referral form to Mind in Harrow: Mind in Harrow, First Floor, 132 – 134 College Rd, Harrow HA1 1BQ Email: [email protected] Tel: 020 8426 0929</p><p>If you would prefer send your referral one of our specialist information & advice services directly, their contact details are provided below:</p><p>For people who are 60 years and over and people with dementia Age UK Harrow, 3rd Floor, Premier House, 1 Canning Road, Wealdstone HA3 7TS Email: [email protected] Tel: 020 8861 7980</p><p>For people with disabilities Harrow Association of Disabled People (HAD), The Wealdstone Centre, 38-40 High Street, Wealdstone, HA3 7AE Email: [email protected] Tel: 020 8861 9920 </p><p>For carers Harrow Carers, 376-378 Pinner Road, Harrow HA2 6DZ Email: [email protected] Tel: 0208 868 5224</p><p>For people with learning disabilities and/or autism and their carers Harrow Mencap, 3 Jardine House, Harrovian Business Village, Bessborough Road, Harrow HA1 3EX Email: [email protected] Tel: 0208 423 7382</p><p>For people with mental health problems Mind in Harrow, 1st Floor, 132-134 College Road, Harrow HA1 1BQ Email: [email protected] Tel: 020 8426 0929</p><p>FOR OFFICE USE: Referral ID number 2</p>