Personal Health Budget (PHB) Referral

Personal Health Budget (PHB) Referral
Criteria

All referrals must be made by an NHS duty of care/clinician.

We will only ask for data once. Please fill in the form as completely as possible.

Core Arts works in partership with ELFT and GDPR regulations, so please attach any 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 will need to submit your PHB application to our PHB Brokerage Service via this form. The brokerage team will support you through the funding application process.
Have you already submitted the PHB Brokerage form?

YesNo
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, please contact Caitlin at cbostoningham@corearts.co.uk or speak to a membership team at 0208 533 3500.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Tour/Visit

MonthDayYear
Date
NHS number*
National Insurance Number*
If you don't have your National Insurance Number, please write 'Unknown' in the box. However, Core Arts will require this information - if you don't have it now it will be requested by the membership manager to offer membership.
Telephone*
Email
example@example.com
Postcode
Gender
Transgender
Sexual Orientation
Ethinicity
Accommodation Status
Does your client have other agencies involved with their care (i.e. housing support, substance use)

YesNo
If yes, by which organisation
Section 2. Care team information
ELFT Care Team
Care Coordinator/Referrer Name
Email*
example@example.com
Telephone/Mobile
GP Name/Surgery
Section 3. Client clinical details
Cluster Number*
This info is required
Primary diagnosis information*
Secondary diagnosis information
Please provide a brief outline of warning signs/triggers for this client or description of relapse indicators (membership team may discuss at enrolment support and agree response plan):*
Are there plans for discharge from ward? (If applicable)
If yes
Are there plans for discharge from care coordination/team?
If yes
Is the patient currently under

Section 2Section 3Informal impatientSection 17 leaveCPACTOSection 37/41 or Section 37Not applicableOther
If Other, please state
Please confirm if your client has Section 117 status*

YesNo
How Many times has the client been hospitalised
In the past year?
Five years?
How many times has the client required crisis support/ home treatment to avoid relapse or hospitalisation
In the past year?*
Five years?*
Are there issues regarding compliance with care team or medication for this individual?

YesNo
Does the person consider these issues ?

YesNo
Please select and attach relevant document to the application, if applicable

Dialogue +Risk assessmentMy PHB Support PlanOther
Please upload the selected document here

Browse Files

Cancelof
Section 4. Wider support planning and pathways options
Please specify the length of PHB
Please specify access amount (package type)

1 course (£45 per week)2 courses (£70 per week)Other
Courses of interest (1st option)
Courses of interest (2nd option)
Have you received the budget live email?

YesNo
Would you consider the person to be eligible for personal budget or direct payments (Care Act 2014) after this PHB is completed?

YesNo
Accessibility and disability notes
Please tick all which apply to the client*

Dyslexia & other specific learning difficultiesEpilepsyHearing ImpairmentMobility difficultiesVisual ImpairmentOther
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*

YesNo
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 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.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Personal Health Budget (PHB) Referral

Section 1. Prospective member details

Section 2. Care team information

Section 3. Client clinical details

Section 4. Wider support planning and pathways options

Section 5. Consent and referrer details

Section 6. Terms and Conditions