IM2C - Service Referral Form

Include Me 2 Club SCIO - Service Referral Form
Welcome to Include Me 2 Club SCIO, this referral form is designed to give us as much detail and information to support you on your journey.

It takes you through the process of identifying:
- Service of interest
- Information about you or the person you are referring
- Understanding your aspirations and outcomes
Please take the time and detail as much information you have, can input and helps us get the best picture of your needs and services you require.

Thank You

How can we help?
Please select the activity, programme or service you/they are interested in or making a referral for. You/they can select more than one option, if suitable.

Buddy Up - 1-2-1 WorkerHub Club - Day ProgrammeSocial Blend ProgrammeTransitions SupportUnsure, would like to chat with someone in more detailOther
In your own words, tell us how Include Me 2 Club can make a difference or help in your/their life or stage of your journey?
What is your/their goals, dreams or aspirations? What are you/they trying to achieve? The more you can tell us the best we can match your/their needs.

Personal Details

Please provide the details of the person you are referring to Include Me 2 Club
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number
Contact Mobile Phone Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
Age
How do you identify yourself?
Do you have any communication needs?
How best can we communicate with you?
What way can we best can we communicate with you?

TelephoneTextEmailLetterOther

Your current circumstances
At what stage are you/they at in life journey?
What is your/their living circumstances?

Tell us what Session/Days you/they are looking to get involved or attend a service. You can mark which days you are available by placing a "Y" in the square or help us understand which days you are busy by placing a "X" on Days below:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Evening

If you/they have a specific need or availability pattern, please give us as much detail as possible to help match your needs to services.
Do you/they currently attend or take part in any activities, services, programmes or providers? If "Yes" please tell us When (Days/Times), Where (Locations) and Who (Operator/Charity/Organisation) provides the service, so we can link and liaise with them (if required) around planning, reviews, understanding journeys between etc.
Emergency Contact

First NameLast Name
Emergency Contact Email
example@example.com
Emergency Contact Phone Number
Emergency Contact Mobile Number

The Person Making the Referral
What capacity are you making this referral?
Referrers Name

First NameLast Name
Referrers Email
example@example.com
Contact Phone Number
Contact Mobile Number
Does the person/you have a transitions plan / care plan in place?
If you have a copy of your/their care, transitions or wellbeing plan, that you can share with us, please upload it here.

Cancelof
Does the person/you have a care budget in place?

About your/their abilities and care needs
Everyone who attends Include Me 2 Club is unique, amazing and has a range of abilities, things they can do and sometimes things they find a challenge or difficult. To understand you needs, and find out what superpowers you have and things you might need a little help with please tell us below
What is your/their superpower?
Do you/they have a specific condition or diagnosis?
Do you/they require any form of personal care?
Do you/they require any medication to be dispensed? (given to you by someone else)
Include Me 2 Club SCIO is not a care provider and do not provide any form of personal care or medication support. If you answered "YES" to any of the above questions it may be that you will require "Support" from a Care Provider to deliver your needs alongside taking part in our activities, services and events.

We can of course assist you in identifying the best route forward for you or let you know about the different options available to you. We may need to discuss your personal needs before we can advise which option may be best.
Do you/they have a personal assistant, paid carer, support worker or care provider in place to support your personal care and medication needs?
If you/they have a care worker or care provider in place, please tell us who and how we can contact them to liaise about your care and support.
Any other information in relation to your condition, medical needs or care can go here, as much detail will help us best meet your needs.

Thank You

We know this information can be hard, we're sure you've had to tell it and probably repeat it time and time again. We know this can get frustrating, can be emotional, but now you have shared with us all the details we need. We can now look at the best options for you/the person you are referring to us.

So what next?
1. We will acknowledge your referral
2. We will look over your referral in greater detail
3. We will look to contact you to discuss your/their needs in more detail or answer any questions we or you/they may have
4. We will look to organise a meeting to meet, share ideas and get to know you/them better
5. We will organise a visit or experience day at the chosen service (if applicable)
6. We will then look at offering you a place or service agreement (if applicable)
And if everything is satisfactory we will then welcome you/them into our services based on the terms you request as part of your agreement. We will keep in touch and provide you/them with regular updates, feedback and will feed into annual reviews or hold our own to ensure we are on track, meeting the outcomes and expectations we hope to achieve.

N.B We will only use your information to provide the membership services you have chosen to participate in. All details you provide are kept confidential by Include Me 2 Club, and only minimal information is shared with our funders and trusted partner organisations and will not be given to others without your prior permission, unless in an emergency situation for use by Health Care or Police Officials.

Our policy meets the General Data Protection Regulations (GDPR), Include Me 2 Club is also registered with the Information Commissioners Office and policies, practices are compliant with Cyber Essentials.

Should you wish to contact us:
- Include Me 2 Club SCIO
- Hub at James McGuire | 124 Main St | Barrhead | G78 1SG
- 0141 881 0544
- info@includeme2club.org.uk
Date completed

MonthDayYear
Date
Signature

Clear
Please verify that you are human*
Should be Empty:

	Very Good	Good	Fair	Poor	N/A
Peer Relationships
Response to Authority
Social Interaction
Punctuality
General attitude to tasks
Overall behavior
Confidence
Independent skills

	Very Good	Good	Fair	Poor	N/A
School
College
University
Job
Volunteering

Include Me 2 Club SCIO - Service Referral Form

How can we help?

Personal Details

Your current circumstances

The Person Making the Referral

About your/their abilities and care needs

Your/their dreams, hopes and aspirations