Stay connected PHB referral

Stay connected PHB referral
Eligibility criteria
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.

Please note the Stay Connected PHB consists of a smart phone that has the value under £100, if you would like to choose a specific model with the PHB holder please include specifics in your referrral. Otherwise we will likely purchase a phone similar to Motorola Moto G14 128GB. If a SIM card is requested it will be Giff Gaff (monthly, no contract. 20GB goody bag for £10 covering 3 months usage).
Please confirm this application meets the above eligibility.*

Yes, I understand
Do you agree to the brokerage service holding info for purpose of PHB?*

Yes
Referrer details
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
PHB holder
Name*

First NameLast Name
NHS number *
Please imput number in this format 111-111-1111
Date of birth*

DayMonthYear
Email address*
example@example.com
Telephone number*
Please enter a valid phone number.
Address*
Postcode*
Borough*
PHB Holder demographics
Gender*
Ethnicity*
Sexual orientation*
Is the service user on s117 aftercare?*
Accommodation status*
Employment status*
Have they been in the armed forces*
Delivery preferences

Please advice where the phone should be delivered
Address*
Moblie number only*
For delivery updates
The Mental Health Recovery Goal

Stay connected
The starting point to any PHB request is the recovery goal.
Summarise the mental health recovery goal and how the PHB will support that goal:*
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)
Cancelof
Please state the date you will plan to review the PHB*

DayMonthYear
This should be in line with other scheduled reviews and no longer than 3months from the budget live date
Stay Connected PHB request
Please select an option*
Please select colour*
If you require a different model from the phone offered by Stay Connected please provide specific details including a weblink in the box below. Please note for the type of this PHB the phone will need to be aroiund £100.
Weblink
Additional information*
Measuring impact
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*
Using the PHB safely
Are there any risks associated with the PHB? How will these be mitigated?*
If you wish for the data to be extended over the 3 months agreed, you will need to submit a review and request for the extension (up to 12 months).

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?*
Should be Empty:

Stay connected PHB referral

Eligibility criteria

Referrer details

PHB holder

PHB Holder demographics

Delivery preferences

The Mental Health Recovery Goal

Stay Connected PHB request

Measuring impact

Using the PHB safely