Personal Health Budget (PHB) Referral

  • Personal Health Budget (PHB) Referral - S.117

    Core Arts Membership (non notional pathway)

  • Criteria

    All referrals must be made by an NHS duty of care/clinician with consent from the PHB holder.

    Please fill in the form as completely as possible.

    Core Arts works in partership with ELFT and GDPR regulations, so please attach any relevant forms that make this referral as efficient for you as possible.

    For step-by-step guidance on the PHB referral process, click here.

    Alongside this referral you should have already submitted your PHB application to our PHB Brokerage Service via this form for approval. The brokerage team will support you through the funding application process.

    Please note: As approval for this membership is over £500 - Approval will be sought via the ELFT PHB Oversight Panel.  

  • Section 1. Prospective member details

  • Please fill in all sections of this referral in order for us to assess for eligibility for the membership.

    If you have any queries about membership, speak to a membership team at 0208 533 3500.

  • Date of Birth*
     - -
  • Date of Tour/Visit
     - -
  • Does your client have other agencies involved with their care (i.e. housing support, substance use)

  • Section 2. Care team information

  • Section 3. Client clinical details

  • Is the patient currently under
  • Please confirm if your client has Section 117 status*

  • How Many times has the client been hospitalised

  • How many times has the client required crisis support/ home treatment to avoid relapse or hospitalisation

  • Are there issues regarding compliance with care team or medication for this individual?
  • Does the person consider these issues ?
  • Please select and attach relevant document to the application, if applicable
  • Have you already submitted the PHB Brokerage form?*
  • Browse Files
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  • Section 4. Wider support planning and pathways options

  • Please specify access amount (package type)

  • Have you received the budget live email?
  • Would you consider the person to be eligible for personal budget or direct payments (ASC- Care Act 2014) after this PHB is completed?

  • Accessibility and disability notes

  • Please tick all which apply to the client*

  • Section 5. Consent and referrer details

  • Please confirm if your client is aware and has consented to the following statement as we will be contacting them directly to invite them to engage*

  • Thank you for completing this referral, we will be in contact as soon as possible!

  • Section 6. Terms and Conditions

  • To be read and signed by the referrer.

    I agree this non notional (funded) PHB referral (for a minimum of 13 weeks access) will be reviewed by the referrer in line with the review dates set in the PHB Support Plan and in collaboration with the Core Arts Membership Team.

    I agree to set up the payment with my client to ensure membership funding is received by Core Arts.

    I agree to liaise directly with Core Arts re client welfare and issues arising during this PHB, and acknowledge Core Arts will be in contacts regarding an concerns regarding your patients wellbeing or their ability to access as soon as possible to work in partnership.

    Continued membership or move on options past the point of the initial PHB will be discussed with the membership team.

  • Date*
     - -
  • Should be Empty: