Referral Questionnaire

Agree or disagree with the above statement.*

Have you been in contact with PKAVS or CILPK before?*

Question 1 - Are you the person who is in need of / receiving support? *

Question 2 - Are you an unpaid carer who is looking for support for yourself? *

If yes to question 2 are you happy for your referral to be allocated to a PKAVS Carers Centre*

Question 3 - A bit about you (the referrer)*

Please can we have your name and place of work if you are a professional/third sector filling in this form

e.g. Maria Beckett social worker Perth Access Team

If you answered other to question 3 please specify

Full Name

First NamePreferred name if appplicableLast Name

Gender

Date of Birth

Age

years

Ethnicity

Address

Street Address

Street Address Line 2

City

Post Code

Email

example@example.com

Landline

Area CodePhone Number

Mobile Number

Contact

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?’

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

Next of Kin details if applicable

Name

First NameLast Name

Street Address

Street Address Line 2

City

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

City

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

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, PKAVS or CILPK 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) I give my consent to Support Choices to act and advocate on my behalf.

By giving this consent, I authorise Support Choices staff when necessary to:

Attend meetings with me.
Contact relevant professionals or organisations.
Speak or write on my behalf.
Request access to information or documents I am entitled to.

Support Choices agrees to:

Remain independent and free from conflicts of interest.
Support me to have my voice heard.
Provide information to help me make informed decisions.
Keep me updated on my case.

Limitations:

Support Choices cannot guarantee a particular outcome.
They are not responsible for commitments I make without their knowledge.
They cannot take legal action but may help me access legal support.
Right to Withdraw:
I understand I can withdraw my consent at any time. If I do, Support Choices may no longer be able to provide services related to this consent.

This consent will remain in place until my issue is resolved or I withdraw it. My personal information will be handled securely and only shared with trusted third parties where necessary, in line with data protection laws.

I AGREE TO THE ABOVE TERMS & CONDITIONS*

YesNo

Referral Questionnaire

Assistance

Details below of the person who is referred

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.