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) in City and Hackney to help them work towards a 'Stay connected' mental health recovery goal.

If you like to discuss your Stay Connected PHB referral before submitting please contact the ELFT PHB team at elft.phb@nhs.net. 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 subject to s.117 aftercare and DIALOG+ support planning
- a resident of City and Hackney
- have recourse to public funds, unless receiving S117 aftercare (see NHSE right to have guidance, section 4.4)
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 note - you can apply directly for a phone and 6 month data package via the dedicated charity: SimPal www.yoursimpal.com without applying for PHB.

A '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 OR we can offer £30 credit - please advise the preferred method on application).
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*
It is essential that you agree that you will be working with the PHB holder alongside the full duration of the PHB, or it is your responsibility to ensure that there is an allocated clinician to provide support until PHB closure.

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*
Mobile number for delivery updates*
For delivery updates
Preferred timings for delivery*
Please advise us to try and avoid any issues
The Mental Health Recovery Goal

'Stay connected'
The starting point and purpose 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 ensure the type of SIM/ Data suits individual preferences and is in line with the continued Recovery plan
Please select colour preference*
Please note this is dependant on availability*
If requesting SIM/ Data please provide the email address the Giff Gaff account will be linked to
example@example.com - the email will be required to access the giff gaff account
If you require a different model from the phone offered by Stay Connected please provide specific details including a weblink in the box below. We encourage this, to ensure the phone is personalised. Please note for the type of this PHB the phone will need to be around or under £100, including delivery.
Weblink - Please provide a Personalised choice (make/ model)
The PHB team tend to use Argos as they have reliable delivery times/ slots - options are not limited to this.
Please include cost / delivery cost and any additional information (please also include suitable/ preferable delivery times)*
Please check specifics from chosen website.
Measuring impact

* You agree to review these scores within 4-6 weeks of 'Stay Connected' PHB provided.
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 following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I found it difficult to get started with everyday tasks*
Answer the following question in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I felt able to trust others*
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I felt unable to cope*
Answer the following two questions in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I could do the things I wanted to do*
I felt happy*
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I thought my life was not worth living*
Answer the following two questions in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I enjoyed what I did*
I felt hopeful about my future*
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I felt lonely*
Answer the following question in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I felt confident in myself*
Using the PHB safely
Are there any risks associated with the PHB? How will these be mitigated? Please include how the data/ SIM packages will be paid for after the 3 month period, this plan is required*
Please ensure the onward payment for data/ SIM must be agreed with the PHB holder, the Giff Gaff account details will be provided to update the accounts payment details with a personal card/ account.
Continued Recovery Goal*
The PHB account with funds for the 3 month period will be closed after the final payment, the Giff -Gaff account and log in is provided when the budget goes live.
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