Referral Questionnaire

Referral Questionnaire

Please provide accurate and complete information for self, family, or health care/social work referrals to the best of your ability.
Details below of the person who is referred. Press the tab key on your keyboard to move through the form
Full Name

First NamePreferred name if appplicableLast Name
Gender

MaleFemalePrefer not to sayNon Binary
Date of Birth

DayMonthYear
Age
years
Address

Street Address

Street Address Line 2

CityState

Post Code
Email
example@example.com
Landline

Area CodePhone Number
Mobile Number
Do you know if you are eligible for Self Directed Support (social care)?

YesPre Assessment/waitingDon't knowNo
Do you currently have Self Directed Support in place?’

Yes - SDS Option 1Yes - SDS Option 2Yes - SDS Option 3Yes - SDS Option 4NoDon't know
Are you currently receiving SDS Support from another agency?

YesNo
If you answered Yes above please specify.
How did you hear about us?

Social workerOnline social mediaAnother third sector organisationOther
If other please state below
Background and reason for referral
Do you have any diagnosed health problems?
If you have any injuries, please list them.
Any other relevant information
Emergency and Support Contacts
Next of Kin details if applicable
Name

First NameLast Name
Street Address

Street Address Line 2

CityState / Province

Post code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to you
Social worker details if applicable
Name

First NameLast Name
Street Address

Street Address Line 2

CityState / Province

Post code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social work team
Name and phone no if not already listed above
In the first instance please state who we would make the initial contact with?
Name and phone no if not already listed above
We take your safety and the safety of our Community Workers very seriously, please answer the next set of questions about Home Visits.
During our home visit would you like us to wear a face mask?
During our home visit will anyone else be present at the initial meeting?
If you answered 'Yes' please can you expand
Do you have pets at home?
If you answered 'Yes' please can you expand
1.) I am happy for Support Chocies to keep my records on file in line with Data Protection and GDPR.

2.) To the best of my knowledge, the information I have given is correct.

3.) If referring on someone’s behalf I can confirm I have permission from them to do so.

4) Your privacy is important to us. If necessary, we may share details with trusted third parties, ensuring compliance with data protection laws. Rest assured, we prioritise safeguarding your personal information and will never disclose information without your consent.
I AGREE TO THE ABOVE TERMS & CONDITIONS*

YesNo
Should be Empty:

Referral Questionnaire

Emergency and Support Contacts

We take your safety and the safety of our Community Workers very seriously, please answer the next set of questions about Home Visits.