Independent Living Hub Contact Record
Service Details
Are you in receipt of Short Breaks via Camden or Direct Payments(if you answer no, you are not eligible for this project)?
*
Yes
No
Have you been referred by Camden Council for the ILH 1-2-1 project?
Yes
No
Which session(s) would you like to attend?
*
Tuesday Group ILH (independent) 16:00-18:30
Monday 1-2-1 ILF (supported) 16:00-18:30
Tuesday 1-2-1 ILF (supported) 16:00-18:30
Wednesday 1-2-1 ILF (supported) 16:00-18:30
Thursday 1-2-1 ILF (supported) 16:00-18:30
Friday 1-2-1 ILF (supported) 16:00-18:30
Personal details
First Name
*
Last name
*
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Gender Neutral
Male
Non-binary
Not Listed
Pan Gender
Prefer not to say
Transgender Female
Transgender Male
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Briefly, please state your main area or additional need(s) and/or disability. (You will be able to give more detail later on in this form.)
Primary Contact / Emergency Contact
First Name
*
Last Name
*
Relationship to you
*
Parent
Guardian
Social Worker
Foster Parent
Trusted Adult
Carer
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Secondary Contact
First Name
Last Name
Relationship to you
Parent
Guardian
Social Worker
Foster Parent
Trusted Adult
Carer
Other
Address
Post Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
School/College Details
School/College Name
*
Are you eligible for Free School Meals?
Please Select
Yes
No
Cultural Background
Ethnicity
*
Arab
Asian Bangladeshi
Asian Indian
Asian Pakistani
Asian Other
Black African
Black Caribbean
Black Other
Chinese
Chinese Other
Mixed Asian / White
Mixed Black African / White
Mixed Black Caribbean / White
Mixed Other
Other
Prefer not to say
White British
White European
White Gypsy or Irish Traveller
White Other
Religious Background
*
No Religion
Muslim
Hindu
Sikh
Buddhist
Jewish
Christian
Not Listed
What religious considerations do we need to make for you like prayer, holidays or food etc?
Communication Details
Is English your first language?
*
Please Select
Yes
No
What other languages do you and your family and carers speak?
Do you use any signing systems?
*
BSL
Makaton
Other
Not applicable
How much adult speech or spoken word do you understand?
*
None
Some
Most
All
How do you like to communicate?
*
Speech
Makaton
Vocalisation & Sounds
Gestures
BSL
What would help you to be more independent?
*
Do you have any special words or signs for people or things?
*
Is there anything else that helps you communicate your views better?
Likes and Dislikes
What are your favourite activities, likes, passions and interests?
*
What are your dislikes or things you are not interested in?
*
Is there anything that makes you upset or angry?
*
Is there anything that makes you scared?
*
What makes you feel better when you are upset, angry or scared?
*
Is there any behaviour that you are trying to discourage and how is this managed?
*
Are you sensitive to loud noises or bright lights?
*
Food and Dietary requirements
How do you express when you are hungry or thirsty?
*
Do you have any dietary requirements or a special diet?
*
What are your favourite foods and drinks?
*
What foods do you dislike or can't eat? Do you have any particular allergies?
*
Do you need any help with eating or drinking, like chopping or mincing food?
*
Do you have any of the following conditions?
*
Gastronomy peg*
Dysphagia*
Non Applicable
If so, how is this cared for and managed? (special equipment etc.)
Doctor/ General Practitioner (GP) Details
GP Practice
*
GP Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Wellbeing and Disabilities
Do you have any mobility impairments?
*
Please Select
Yes
No
If Yes, please give details
Do you use any mobility equipment like a wheelchair, walker or hoist whether sometimes or always?
*
Do you have any visual impairments?
*
Please Select
Yes
No
If Yes, please give details
Do you have any hearing impairments?
*
Please Select
Yes
No
If Yes, please give details
Do you have epilepsy* and how is this managed? (trigger, frequency, duration and treatment)
*
Please Select
Yes
No
If Yes, please give details
Do you have any social, emotional, and/or mental health needs?
*
Please Select
Yes
No
If Yes, please give details
Can you give us any details about your disability diagnosis?
*
Please Select
Yes
No
If Yes, please give details
Do you use any emergency or pro re nata (PRN) medication*?
*
Please Select
Yes
No
If Yes, please give details
Do you take any other medication?
*
Please Select
Yes
No
If Yes, please give details
Do you need help with medical care or medication?
*
Please Select
Yes
No
If Yes, please give details
Do you have any non-food allergies?
*
Please Select
Yes
No
If Yes, please give details
Do you have any other medical conditions that we should be aware of?
Is there anything else we need to know in order to keep you safe?
Transport, Mobility and Accessing the Community
How confident are you traveling on public transport like buses and trains when with a worker or can you travel independently?
*
Travel Independently
Very confident on public transport
Reasonably confident on public transport
Somewhat confident on public transport
Not confident on public transport
Cannot use public transport
Are you interested in becoming an independent traveller if not already?
Do you need any support to walk or move around?
*
Please Select
Yes
No
How safe are you in public whilst crossing the road?
*
How comfortable are you in new places and with strangers?
*
Very confident
Confident
Somewhat confident
Not at all confident
Do you have an awareness of money or value?
*
Please Select
Yes
No
Additional Care Plans and Consent
Do you have any additional care plans?
*
Epilepsy Care Plan
Manual Handling
Dysphagia
Educational Healthcare Plan
Positive Behaviour Care Plan
Diabetes Care Plan
Other care plan
No care plan
If Yes, please upload a copy of these now
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you consent to share your care plans with Wac Arts?
*
Please Select
Yes
No
Individuals or parents/guardians are required to give permission for an authorised Wac Arts first aider to give any immediate and/or necessary first aid treatment. This includes any emergency medical treatment recommended by competent authorities including emergency medical staff.* Please note that no consent means you or your young person will not be able to participate in the programme
*
Please Select
Yes
No
Do you consent for your young person to be taken on offsite trips?
*
Please Select
Yes
No
At Wac Arts, we often use photographs and video footage of our work for publicity, including in digital newsletters and on social media. Please select below if you would like to provide consent for your young person's image to be shared for publicity purposes
*
Please Select
Yes
No
Mailing List
Goals and Target Setting
Which 3 areas would you like to try to develop and learn about whilst on the 1-2-1 ILH project?
Money & Budgeting
Travelling Independently
Food Hygiene & Preparation
Keeping Fit & Healthy
Housekeeping & Looking after Yourself and the Home
Personal & Professional Development
Please select below if you would like to sign up for the Wac Arts mailing list to receive news and updates on our work via email. You can unsubscribe from these emails at any time.
*
Please Select
Yes
No
GDPR Statement
By submitting this form, you acknowledge and provide your consent for us to process and store your data on our secure cloud-based system. All data is stored in accordance with our Privacy Policy and is used to deliver our service.
*
I understand and consent
By submitting this form, you acknowledge and provide your consent for us to share you data with our partners in the short breaks service inlcuding PACE and Camden Council.
*
I understand and consent
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Save
Submit
Should be Empty: