REFERRAL FORM

REFERRAL FORM

SUPPORTED LIVING REFERRAL FORM PLEASE READ CAREFULLY

If you require a different format for thisform, then please contact us. All sections of this form must be completed.Failure to do so may cause delays. If for any reason a section cannot be filledout, please state why. Blank sections will not be accepted. If there is nospace for your answer, please use the extra sheet provided at the end of thisform, thank you. Please be aware that your data may be shared with local authority,Housing associations, Housing Benefit departments; the referral agency thatdirected you to Lyriq Healthcare Ltd and with other bodies (such as Police orthe Courts or Probation – if appropriate) where they have a legal right toaccess. In all such cases, Lyriq Healthcare ltd will ensure that a ‘dataexchange agreement’ is in place, which will ensure that data is only used forlegitimate purposes. This is however subject to one important exception. Insome limited circumstances, we may be legally required to share certainpersonal data, if we are involved in legal proceedings or complying with legalobligations, a court order, or the instructions of a government authority. Inthese instances, we will always endeavour to inform the individual concerned.
Please fill the following in BLOCK LETTERS
Date of Referral:

MonthDayYear
Referral Source Name:

First NameLast Name
Organization/Agency Name:

Organization Name

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Source Contact Information:
Name

First NameLast Name
Email Address:
Email Address:
Address:

Street Address

Full Address

CityState / Province

Postal / Zip Code
Client Information
Name:

First NameMiddle NameLast Name
Date of Birth:

MonthDayYear
Date
Gender:
Preferred Pronouns:

Street Address

Optional

CityState / Province

Postal / Zip Code
Diagnosis: Physical and/or Mental Health
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
Email Address
Ethnicity:

(Optional)

Street Address Line 2

CityState / Province

Postal / Zip Code
Language(s) Spoken:

(Optional)

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name:

First NameLast Name
Emergency Contact Phone Number:
Phone NumberFormat: (000) 000-0000.
Referral Reason
Please describe the reason for referral to our Supported Living services:
Provide a detailed description of the client’s current situation, challenges, and any specific needs that should be addressed.
Client’s Primary Support Needs:
Please specify:
Specify other needs
Is the client currently receiving any other services?
Please provide details:
Service provider(s), type of service, etc.
Medical & Health Information
Primary Health Conditions/Disabilities (if applicable):
Describe any relevant medical conditions or disabilities.
MedicationsCurrently Prescribed (if applicable):
List any medications the client is taking.
Allergies(if any):
List any known allergies.
PrimaryCare Physician/GP:
Name,Contact Information
OtherHealth Professionals Involved in Care:
Listother professionals involved, e.g., specialists, therapists, social worker,LMHT etc
Risk Assessment
please specify:
Specify
Does the client pose any of the following risks?
Pleaseprovide further details on any identified risks:
Providea detailed description of any risks and how they are managed
Specify
Client’s Preferences & Goals
Whatare the client’s preferences for supported living?
Includepreferences regarding location, type of support, cultural needs, etc.]
Client’sGoals and Aspirations (if known):
Outline any goals the client has, such as increased independence, social integration, employment, etc.
Additional Information
Please include any other relevant informationthat will support the referral:
Provide any other details or documentation that will aid in the assessmentprocess.
Referring Agency/Person’s Declaration

I confirm that the information provided inthis referral is accurate to the best of my knowledge. I understand thatadditional information may be required to complete the referral process andwill cooperate as needed.
Signature of Referring Person:
Date

MonthDayYear
ForInternal Use Only
Referral Received by:

Staff Name

Street Address Line 2

CityState / Province

Postal / Zip Code
Assessment Date:

MonthDayYear
Outcome of Referral:
Should be Empty: