Mentoring Plan, Progress and Summary report

1
Which report are you submitting today?please tick as appropriate
Referral (Baseline)
3/6 Month
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Which Move-on Plan?(tick one option only):
End of membership
Wellbeing Network
Personal Budget Application
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Members NameWhat is the Name of the Member that you are submitting the report for?
First Name
Last Name
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Current Course/ Workshops:Which courses does the Member take part in?
Huge
Large
Normal
Small
Ok
Ok
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Time Management & Goal SettingObserved current level from 1 (Being unclear goals/no routine) to 10 (time management/goals)
1
Please Select
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from 1 (Being unclear goals/ no routine) to 10 (time management/ goals)
Score
Notes
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Social Interactions/ Communications SkillsObserved current level from 1 (Difficult communication with others) to 10 (socialising/friendships)
1
Please Select
1
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From 1 (Difficult communication with others) to 10 (socialising/ friendships)
Score
Notes
7
Confidence & Self EsteemObserved current level from 1 (Low self-confidence) to 10 (self-confidence/able)
1
Please Select
1
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From 1 (Low self-confidence) to 10 (self-confidence/able)
Score
Notes
8
Concentration/ MemoryObserved current level from 1 (Unable to concentrate/ forgetful) to 10 (concentration 30mins+)
1
Please Select
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From 1 (Unable to concentrate/ forgetful) to 10 (concentration 30mins+)
Score
Notes
9
Takes Part In (Social) Activities/ Involved In (Creative) CommunityObserved current level from 1 (Forgetful) to 10 (good memory/ rarely miss planned appointments)
1
Please Select
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From 1 (Forgetful) to 10 (good memory/ rarely miss planned appointments)
Score
Notes
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Motivation/ EngagementObserved current level from 1 (Low motivation) to 10 (Achieving/ self motivated)
1
Please Select
1
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From 1 (Low motivation) to 10 (Achieving/ self motivated)
Score
Notes
11
Skill levelObserved current level from 1 (Trying new things) to 10 (aware of strengths & skill ability )
1
Please Select
1
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From 1 (Trying new things) to 10 (aware of strengths & skill ability)
Score
Notes
12
Independence from support servicesObserved current level from 1 (Need support) to 10 (Good initiative/ self sufficient)
1
Please Select
1
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From 1 (Need support) to 10 (Good initiative/ self sufficient)
Score
Notes
13
Reduction in incidence/ relapseObserved current level from 1 (Frequent intervention/ Leave rescinded from ward) to 10 (No occurence)
1
Please Select
1
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From 1 (Frequent intervention/ Leave rescinded from ward) to 10 (No occurence)
Score
Notes
14
Appropriate use of clinical teamObserved current level from 1 (Overuse or avoidance) to 10 (Good rapport/ support plan/ Discharge)
1
Please Select
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From 1 (Overuse or avoidance) to 10 (Good rapport/ support plan/ Discharge)
Score
Notes
15
Medication complianceObserved current level from from 1 (Unengaged/ requires support or intervention) to 10 (Self managing)
1
Please Select
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From 1 (Unengaged/ requires support or intervention) to 10 (Self managing)
Score
Notes
16
Mental healthObserved current level from 1 (Unstable/ crisis) to 10 (Strong coping - strategies/ resiliance)
1
Please Select
1
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From 1 (Unstable/ crisis) to 10 (Strong coping - strategies/ resiliance)
Score
Notes
17
Use of servicesObserved current level from 1 (Dependence) to 10 (Mainstream/ Wellbeing/ preventative)
1
Please Select
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From 1 (Dependence) to 10 (Mainstream/ Wellbeing/ preventative)
Score
Notes
18
Considering other opportunitiesObserved current level from 1 (Low motivation/ fear) to 10 (Know what i will do next/ goals/ plans)
1
Please Select
1
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From 1 (Low motivation/ fear) to 10 (Know what i will do next/ goals/ plans)
Score
Notes
19
Holistic and cultural needsObserved current level from 1 (No access) to 10 (regular events/ participation)
1
Please Select
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From 1 (No access) to 10 (regular events/ participation)
Score
Notes
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Coping skillsObserved current level from 1 (No resiliance) to 10 (can articulate and act on skills)
1
Please Select
1
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From 1 (No resiliance) to 10 (can articulate and act on skills)
Score
Notes
21
Physically active/ health & wellnessObserved current level from 1 (Self neglect/ no motivation) to 10 (participating in health focussed activities)
1
Please Select
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From 1 (Self neglect/ no motivation) to 10 (participating in health focussed activities)
Score
Notes
22
Accessed or used Hht Service?Over the period of last 3-6 months has your client accessed or used Hht Service?
Yes
Please Select
Yes
No
Please select
If yes, how many?
23
Admitted To Hospital?Over the period of last 3-6 months has your client been admitted to hospital?
Yes
Please Select
Yes
No
Please select
If yes, how many?
24
Access Respite Services?Over the period of last 3-6 months has your client accessed Respite Services?
Yes
Please Select
Yes
No
Please select
If yes, how many?
25
Emergency Care Team Appt?Over the period of last 3-6 months has your client had Emergency Care Team Appt?
Yes
Please Select
Yes
No
Please select
If yes, how many?
26
Use Of GP (Mh)?Over the period of last 3-6 months has your client seen GP (Mh)?
Yes
Please Select
Yes
No
Please select
If yes, how many?
27
Use Of A&E?Over the period of last 3-6 months has your client used A&E?
Yes
Please Select
Yes
No
Please select
If yes, how many?
28
Increase in Care (Ii.e. Allocated Care Coordinator)?Over the period of last 3-6 months has your client had increase in care (I.e. Allocated Care Coordinator)?
Yes
Please Select
Yes
No
Please select
29
Decrease in Care (i.e. Discharged To Primary Care)?Over the period of last 3-6 months has your client had decrease in care ( i.e. Discharged To Primary Care)?
Yes
Please Select
Yes
No
Please select
30
Changes To Section (i.e. Cto)Over the period of last 3-6 months has your client had changes to section (i.e. CTO)?
Yes
Please Select
Yes
No
Please select
31
Change In Housing Status - Increase SupportOver the period of last 3-6 months has your client had changes in Housing Status - Increase Support?
Yes
Please Select
Yes
No
Please select
32
Change In Housing Status - Decrease SupportOver the period of last 3-6 months has your client had changes in Housing Status - DEcrease Support?
Yes
Please Select
Yes
No
Please select
33
Use Of Forensic Services/ Cjs InvolvementOver the period of last 3-6 months has your client Use Of Forensic Services/ Cjs Involvement?
Yes
Please Select
Yes
No
Please select
34
Medication compliance comments:
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Small
Ok
Ok
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Other Comments:
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Ok
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Summary of Progress:
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Ok
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Suggestions/feedback:
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Ok
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Your Email
example@example.com
Should be Empty: