New Customer Registration Form

Prospective Client Application / Referral Form (* means information is obligatory for a referral but leave blank & tap NEXT if any field is not applicable or can be completed later e.g. upon initiation of a contract)

Please note that more detailed information can be provided later! Not all fields in this form need to be completed before first visit - just key information is required upon application / referral Information will be kept in the strictest confidence
Details of person completing form (completing this form will usually facilitate a visit to the day centre followed by three, free assessment sessions after which there will be discussion regarding a possible day support contract):
Your Full Name:*

First NameLast Name
Your Tel. No. or your Organisation's Tel. No.: ☎️ (Please make sure you provide a contact telephone no. or email address or both)

Area CodePhone Number
Your Email Address or your Organisation's Email Address: 📨 (Please make sure you provide a contact telephone no. or email address or both)
example@example.com
Need to know more about Centa Co? - our Google page has lots of photos, videos and over 30 client reviews 👍 ~~~~~~~~~~~~~~~~ Centa Co has been a contracted provider of day services for Medway Council since 2015 (Supplier Number 03605500) ~~~~~~~~~~~~~~~~ Centa Co also has contracts with Kent County Council and the NHS
How did you hear about us?:
Please Specify:
Your Organisation (if applicable):

Please note that any client requiring personal / toileting care would need to be accompanied by their own one-to-one support worker
Owing to safeguarding reasons, female clients must be accompanied by a support worker from Mondays to Fridays but they can attend unaccompanied on Saturdays
Name of Prospective Client:*

First NameLast Name
Your Relationship to Prospective Client:*
Date of Birth (person must be at least 18 years old):
Gender of Prospective (Male / Female):*
Address of Prospective Client:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Prospective Client: ☎️

Area CodePhone Number
Any special comunication requirements:
Main interests of prospective client / activities they like:

Lives with Parents / Lives under Supported Living / Lives Under Foster Care or Shared Lives / Other: 🏠
Next of Kin (name / relationship / contact details):

Learning Disability / Autism / ADHD / Brain Injury / Other:*
GP details incl. Address & Phone No. 🏥
Medical Conditions (e.g. epilepsy and triggers; asthma; diabetes). This can be provided later upon commencement of assessment sessions:

Medication Client is on: 💊
Please note that detailed medical information won't be required for first visit to day centre, if prospective client is accompanied 😊
Self medicating?:
Observation of taking medication required?:
Day centre to administer medication?:

Details of any Hospital Admission within past 5 years:
Known Allergies:
Challenging behaviours incl. meltdowns and triggers (detailed information on these can be given later). Centa Co is unable to support persons with highly destructive or aggressive behaviours
Risk Assessment info. (not required for an initial visit) e.g. history of wandering off or over-trusting strangers; past financial abuse; phobias; obsessive behaviour; paranoia; hyperactivity; tripping; coordination; choking; mood fluctuations.
Any area in which prospective client has been deemed to not have Mental Capacity plus details:

Council Funding in Place / Council Funding to be Applied for / Self Funding?: 💸
Any contact that will help application e.g. Social Worker at Medway Council / Kent County Council / NHS or other:

Preferred days and times of support (or leave blank if to be confirmed):
Would client be accompanied by a one-to-one Support Worker?:
Requires minibus transport to and from day centre (cost is £2.50 per day for pickups within 8 miles of Chatham) or can make own way to and from day centre?: 🚘

Any extra information you'd like to provide now (more detailed information will be required anyway upon initiation of contract incl. a 40 point risk assessment covering all risks and behaviours):
What would you like Centa Co to do next? e.g. us to contact yourself, the person completing form / you to contact us / us to contact your organisation / us to contact next of kin or a parent / us to contact prospective client themself / Centa Co to be contacted (Tel. 07799 890635 medwaydaycare@gmail.com): PLEASE MAKE SURE YOU'VE LEFT EITHER A PHONE NUMBER OR AN EMAIL ADDRESS FOR US TO CONTACT *
Should be Empty:

Prospective Client Application / Referral Form (* means information is obligatory for a referral but leave blank & tap NEXT if any field is not applicable or can be completed later e.g. upon initiation of a contract)