PHB Referral

Personal Health Budgets (PHB) are offered to adults receiving support from East London Foundation Trust (ELFT) to help them work towards a mental health recovery goal.

If you like to discuss your PHB referral before submitting please contact the ELFT PHB lead Bonnie at bonnie.studd@nhs.net or 07436027771. Please see relevant checklist information and guidance notes.

Any issues submitting your referral, please follow up via email at PHB@corearts.co.uk.

To receive a PHB, the person must be*:

an adult (18+)
receiving mental health support from East London Foundation Trust
a resident of City and Hackney, Newham or Tower Hamlets
have recourse to public funds, unless receiving S117 aftercare (see NHSE right to have guidance, section 4.4).

Please note: if you're referring someone for a PHB through primary care, please contact us on the details above.

To make a referral to the service:

Please complete the referral form with the person referred for a PHB [please note the referral form includes a "quality of life" (ReQol/10) or DIALOG+ questionnaire that will need to be completed by the person].

Please upload and submit a PHB support plan that has been completed with the person and offer them a copy.

Please discuss the referral with the approving manager so they are aware we will be in contact seeking authorisation.

If you are using direct payments for this PHB, the PHB holder will need to sign a DPA prior to the set up, we will be in touch to request this form to be completed to progress the application.

Please tick this box to confirm that the person you are referring meets the eligibility criteria**

Yes, I understand - tick to continue

Please check the box if you understand that by submitting this personal information you are consenting to Core Arts holding and using it in accordance with our privacy policy.*

Yes, I understand

If you need help or have questions about any aspects of the Personal Health Budget process please contact us at PHB@corearts.co.uk.

Full Name*

First NameLast Name

Telephone number*

Please enter a valid phone number.

Email address*

example@example.com

Borough*

Team*

Role*

Is another professional involved with this PHB?

Name

First NameLast Name

Role

Team

Email address

example@example.com

Name*

First NameLast Name

NHS number*

Please imput number in this format 111-111-1111

Date of birth*

Date

Email address*

example@example.com

Telephone number*

Please enter a valid phone number.

Address*

Postcode*

Borough

Gender*

Ethnicity*

Sexual orientation*

Is the service user on s117 aftercare?*

Accommodation status *

Employment status*

Have you been in the armed forces?*

The starting point to any PHB request is the recovery goal.

In you answer below please offer the following;

What is the mental health recovery goal?
How does the item/ activity requested support that goal?
Why is this important to the person? E.g. Why have they selected this as their chosen support?

Please be as personalised and detailed as possible to demonstrate the individuals goals and voice in regards to the PHB.

Summarise the mental health recovery goal and how the PHB will support that goal:*

Please provide full description (item description section):*

If there are more than 3 items related to the PHB you are applying for, please use this section to specify the additional items.

Please select the main area this request relates to:*

Please select any other additional areas that are support by this request (optional):

Further additions (optional):

Please upload your plan (DIALOG+, PHB plan, ILP)

Please select an outcome measure*

DIALOG+ monitoring

1 – Totally dissatisfied

2 – Very dissatisfied

3 – Fairly dissatisfied

4 – In the middle

5 – Fairly satisfied

6 – Very satisfied

7 – Totally satisfied

How satisfied are you with your mental health?*

How satisfied are you with your physical health?*

How satisfied are you with your job situation?*

How satisfied are you with your accommodation?*

How satisfied are you with your leisure activities?*

How satisfied are you with your relationship with your partner/family?*

How satisfied are you with your friendships?*

How satisfied are you with your personal safety?*

How satisfied are you with your medication?*

How satisfied are you with the practical help you receive?*

How satisfied are you with your meetings with mental health professionals?*

ReQoL/10 monitoring

Answer the questions in relation to last week.

1 – None of the time

2 – Only occasionally

3 – Sometimes

4 – Most of the time

5 – Most or all of the time

I found it difficult to get started with everyday tasks*

I felt able to trust others*

I felt unable to cope*

I could do the things I wanted to do*

I felt happy*

I thought my life was not worth living*

I enjoyed what I did*

I felt hopeful about my future*

I felt lonely*

I felt confident in myself*

Please state the date you will plan to review the PHB *

This should be in line with other scheduled reviews and no longer than 3months from the budget live date

Name of item/activity/service*

Website link*

Price (unit cost per session or product)*

Frequency*

Duration (number of weeks/sessions/one- off)*

Total budget amount (quantity x unit cost)*

Payment option*

*Next step

If this budget is under £250 it does not require approval, please fill and sign this DPA agreement and send it back to phb@corearts.co.uk for us to review the application and accept the referral.

Another item:

YesNo

Name of item/activity/service

Website link

Price (unit cost per session or product)

Frequency

Duration (number of weeks/sessions/one- off)

Total budget amount (quantity x unit cost)

Another item:

YesNo

Name of item/activity/service

Website link

Price (unit cost per session or product)

Frequency

Duration (number of weeks/sessions/one- off)

Total budget amount (quantity x unit cost)

If there are more than 3 items related to the PHB you are applying for, please use the item description section above to specify the additional items.

Whole total budget amount request*

Please ensure this is the whole amount requested

What is the continued recovery goal beyond the PHB?*

Are there any risks associated with the PHB? How will these be mitigated?*

Additional information*

How will purchase be made*

Requests over £250 need approval from a team lead/manager

Is the request over £250?*

Please provide the approving managers:

Name*

First NameLast Name

Email address*

example@example.com

Telephone number*

Please enter a valid phone number.

Requests over £750 will be send to e-panel for approval

Is this request over £750*

*Next step

If this budget is under £250 it does not require manager's approval, please fill and sign this DPA agreement and send it back to phb@corearts.co.uk for us to review the application and accept the referral.

Feedback helps us to learn what is working well and what can be improved.

Are you happy to be contacted by a member of the ELFT PHB team to share more about your PHB experience?*

PHB referral

Eligibility criteria

Referrer details

PHB holder

PHB Holder demographics

The Personalised Mental Health Recovery Goal

PHB request

Using the PHB safely

Approval