Appointeeship Referral Form

  • APPOINTEESHIP SERVICE REFERRAL FORM

    All questions contained in this questionnaire are strictly confidential and will form part of the client's confidential file. 

    • Section 1 Referrer Details 

    • 1. REFERRER DETAILS

    • Date of referral
       / /
    •  -

  • Client Risk Assessment

    This risk assessment is designed to assess if a KDC appointeeship service is suitable for the client. Please complete all necessary information to proceed
  • 1 - Does the client have a Criminal History including: - Convictions for financial fraud or theft; Convictions for violent offences; Convictions related to exploitation or abuse; Convictions under the Sexual Offences Act; History of coercive or controlling behaviour.*
  • 2 - Current Legal Status is the client - Under police investigation, On bail or probation, Subject to court orders (e.g., restraining orders, safeguarding orders), Registered sex offender (including notification requirements).*
  • 3 - Behavioural Concerns, does the client have - History of aggression or violence towards staff or others, Known to exhibit threatening or intimidating behaviour, Substance misuse impacting financial decision-making, Mental health concerns that may pose a risk to staff or service integrity.*
  • 4 - Safeguarding Risks - Known safeguarding concerns (e.g., exploitation, neglect), Risk of financial abuse (either as victim or perpetrator), Living in environments with known safeguarding issues.*
  • 5. Capacity and Compliance, does the client - Lack of engagement with support services, Non-compliance with previous financial arrangements, Refusal to provide necessary documentation or access to financial information.*
  • 6. Environmental Factors: - Unstable housing or frequent changes of address, Associations with individuals who pose a risk (e.g., known offenders), Living in high-risk or unsafe environments.*
  • 7. Risk to Organisation, does/could the client pose a - Potential reputational risk to KDC North West, Likelihood of legal disputes or complaints, Resource-intensive support needs beyond service capacity.*
    • Section 2 Client Information 

    • 2 CLIENT INFORMATION

    • Client Title*

    • Client Date of birth*
       / /
    • Section 3 Client Accommodation 

    • 3 CLIENT ACCOMMODATION

    •  -
    • Client Accommodation Category*

    • Client Accommodation funding*

    • Section 4 Client Current Care Provision 

    • 4 CURRENT CARE PROVISION

    • Client Care Provider*

    • Care Funding Type*

    • Is there a Care Plan in place?*
    • Is a Financial Plan in place?*
    • Browse Files
      Cancelof
    • Section 5 Welfare benefits & income and outgoings 

    • 5. CLIENT WELFARE BENEFITS & INCOME & OUTGOINGS SOURCES

    • Rows

    • OUTGOINGS

      list all client outgoings
    • Rows
    • Section 6 Client Assets and Capital 

    • 6. CLIENT ASSETS & CAPITAL

    • Is there an existing Bank/Building Society Account?*
    • Is there an existing Post Office Account?*
    • Does the client own any properties?*
    • Does the client have any investments?*
    • Does the client have any form of inheritance?*
    • Does the client have any stocks or shares?*

    • CLIENTS OWN BANK ACCOUNT DETAILS

    • Section 7 Overview of other circumstances 

    • 7. OVERVIEW OF OTHER CIRCUMSTANCES

    • Is there a current Appointee?*
    •  -
    • Is a Funeral Plan in place?*
    • Has a Will been made?*
    • Is insurance in place for home and/or contents?*
    • Does the client own a motor vehicle or have access to a Motability vehicle?*

    • SIGNIFICANT OTHERS

    • Does the person have any next of kin or significant person?*
    •  -
  •  
  • Should be Empty: