PHB Referral

Discharge 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.

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 eligible for s.117 aftercare (see NHSE right to have guidance, section 4.4).
The following referral form is for PHB requests facilitating discharge from hospital only. There is an alternative PHB referral form for all other PHB requests for mental health recovery.

A recent DIALOG+ plan is required for the PHB referral. The plan should be edited to only include details relevant to the PHB request as it will be loaded to the referral form. Approval from a ward manager will be required for requests over £250 and the items or services will be purchased by the PHB Implementation Team.

If you like to discuss your PHB referral before submitting it, please contact elft.phb@nhs.net.
Any issues submitting your referral, please follow up via email to PHB@corearts.co.uk.
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
Referrer details
Full Name*

First NameLast Name
Telephone number*
Please enter a valid phone number.
Email address*
example@example.com
Borough*
Team*
Role*
Is there a professional in the community assigned to the person you are referring?
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
Date
Email address*
example@example.com
Telephone number*
Please enter a valid phone number.
Address*
Postcode*
Borough
Current ward/address
PHB Holder demographics
Gender*
Ethnicity*
Sexual orientation*
Is the service user on s117 aftercare?*
Accommodation status *
Employment status*
Have you been in the armed forces?*
The Personalised Mental Health Recovery Goal
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 the DIALOG+ plan
Cancelof
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?*
Approx bed days saved with access to PHB*
How will the PHB facilitate discharge from hospital?*
PHB request

Please note the maximum amount of funds are £500 and the PHB timeframe is 3 months.
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)
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
Using the PHB safely
Are there any risks associated with the PHB? How will these be mitigated?*
Where should the item be delivered to? (please state a named person)*
Additional information
Approval
Requests over £250 need approval from an approving ward manager
Is the request over £250?*
Please provide the approving ward managers details:
Name*

First NameLast Name
Email address*
example@example.com
Telephone number*
Please enter a valid phone number.
Feedback helps us to learn what is working well and what can be improved.
Is the person referred happy to be contacted by a member of the ELFT PHB team to share more about your PHB experience?*
Should be Empty:

Discharge PHB referral

Eligibility criteria

Referrer details

PHB holder

PHB Holder demographics

The Personalised Mental Health Recovery Goal

PHB request

Using the PHB safely

Approval