Core Arts Referral & Membership Request

CriteriaAll referrals must be made by an NHS duty of care/clinician. Persons who self refer will need agreement and a clinical referral in order to access this service.It’s important to us that the client choses our service therefore please ensure they have been on a Friday tour and want to be a member and to engage in their creative learning and personal development.

Yes I understand

NameWhat is the Prospective Member's Name?

First Name

Last Name

Date of Tour/VisitWhen did the Prospective Member visit Core Arts?

Date

Date of ReferralWhen was the Prospective Member referred to Core Arts?

Date

Date of BirthWhat is the Prospective Member's Date of Birth?

Date

NI NumberWhat is the Prospective Member's NI Number?

Address (Home)What is the Prospective Member's Home Address?

Street Address

City

Post Code

Country

Address (Ward)What is the Prospective Member's Ward Address?

Street Address

City

Post Code

Country

Phone NumberWhat is the Prospective Member's Phone Number?

EmailWhat is the Prospective Member's Email Address?

example@example.com

GenderWhat is the Prospective Member's Gender?

Male

Female

TransgenderIs the Prospective Member transgender?

Yes

EthnicityWhat is the Prospective Member's Ethnicity?

BoroughWhat is the Prospective Member's Borough?

Allocated Ward Staff/or NamePlease provide Name, Email and Phone Number:

Name

Number

Care Coordinator NamePlease provide Name, Email and Phone Number:

Name

Number

Consultant Psychiatrist NamePlease provide Name, Email and Phone Number:

Name

Number

GP NamePlease provide Name, Email and Phone Number:

Name

Number

Cluster Number* This field is required.Please provide client's cluster number (this info is required):

DiagnosisWhat is the client's diagnosis?

Relevant documents & risk assessmentPlease attach relevant document & risk assessment to the application (Please select which documents you are providing and use the File upload in next step)

CPA

Risk Assessment

Other

File uploadAllowed formats are pdf, doc, docx, xls, xlsx, csv, txt, rtf. Multiple Uploads are allowed

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Please provide reasons why client cannot engage with mainstream opportunities:

Accommodation StatusWhat is the accommodation Status of the client (please tick one):

Accommodation with criminal justice support

Accommodation with mental healthcare support

Accommodation with other (notspecialist mental health) care support

Acute/long stay healthcare residential facility/hospital

Living with parents

Homeless

Mainstream housing

Mobile housing

Sheltered housing (accommodation with a scheme manager or warden living on the premises or nearby, contactable by an alarm system if necessary)

Other

If other, please state

Disability NotesIs the client in receipt of DLA

Yes

Disability DetailsPlease tick multiple if required

Dyslexia & other specific learning difficulties

Epilepsy

Hearing Impairment

Mobility difficulties

Visual Impairment

Other

If other, please stateIf you selected "Other" accomodation atatus, please specify

Sexual Orientationplease tick one

Bisexual

Declined to say

Gay/Lesbian

Heterosexual

Area of needPlease select and leave any comments in the next step

Discharge planning/ transitional support

Engagement with support services

Reduce risk of social exclusion

Early intervention/ risk management/ medication compliance & support

Increase opportunities, learning and personal leisure activity development

Increased self esteem/confidence/ motivation

Appropriate CMHT engagement (reduce reliance/use of service)

Reduced risk of forensic activities engagement (deterrent)

Learning and achievement orientated/ strengths focused

Structure & routine- living skills & responsibilities

Being active/ physical health

Spiritual, cultural opportunities through arts in health

Reduce symptoms of institutionalisation/ challenge expectations (increase engagement)

Increase access to the city and hackney wellbeing network

Support to access a personal budget (if applicable) outcome focused support plan

Regain sense of self, positive personal qualities and skill level (creative ability)

Reduce risk of crisis pathway/ hospitalisation

Comments:Please provide any comments regarding intervention monitoring and outcome focussed planning

Have you secured funding for this membership

YESNO

If yes,If you have secured funding, please provide details

for many days per week?

for how many month?

NameName to go on Invoice

First Name

Last Name

AddressAddress to go on Invoice

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Reference No. or Purchase Order No.Reference Number to go on Invoice

Your Name

First Name

Last Name

Your Email

example@example.com

Your Phone Number

Terms and Conditions* This field is required.As part of the partnership it is required that as care coordinator (or referrer) to feedback on a 3 - 6 monthly basis your professional opinion regarding members progress and our service impact. This is a stipulation ofthe funded contract and an outcome measurement.

Yes, I understand

Please read and signI have informed other relevant clinics or practitioners about this referral and recorded this information on RIO to ensure Core Arts membership is known within the care plan for this individual.I agree for the management team at Core Arts to assess my client for suitability to engage with the preventative service ”City and Hackney Wellbeing Network” and this will be communicated and agreed if appropriate.

Clear

Core Arts Referral & Membership Request