Social Care Referral Form
Social Workers Name
Social workers Email address
Social worker contact number
Age of person to be referred
Which ratio would you consider the person to require? (The Essex Skipper will do their own assessment to identify the required ratio for the setting.)
Small Group Ratio, with the person mostly requiring observation with occasional prompting.
Small Group Ratio, with the person requiring direct supervision at all times.
Small Group Ratio, with the person occasionally requiring 1:1 support.
Small Group Ratio, with the person requiring 1:1 support more than 25% of the time.
Requires 1:1 support for physical needs
Requires 1:1 support for behavioural needs
Requires 1:1 support for cognitive needs
Requires 1:1 support and on occasion a 2:1 support (any person who can become physical with others will be on this level or above).
Requires a 2:1 support or higher more than 25% of the time.
Relevant information of person being referred which will help identify the way the person is supported by the service:
e.g: struggles with loud environments, recent bereavement, medical needs which require staff to administer medical care eg gastrostomy, sexualised behaviours etc...
Please give any information relating the member’s diagnosis relevant to their time at The Essex Skipper
Eg: Wheelchair accessibility, hoisting required, anaphylactic reactions, self harm....
Does the person display any challenging behaviours? If so please state what the behaviours are, the frequency of the behaviour, if there are any known triggers and how are the behaviours managed.
E.g : Flight risk, Hitting others, head butting, damage to property, removing seat belts in vehicles, sexualised behaviour, verbal assaults....
Please state if the person needs any assistance in regards to personal care
Eg wears pads requires changing/ wears pads but changes themself/ colostomy care requires support/ colostomy care independent/ needs prompting to use the toilet / none required
Please list any of the persons special interests
Eg emergency services, Pokemon, trains...
What activities are you most interested in for the person at The Essex Skipper?
Performing Arts workshops
Cooking Sessions
Swimming Sessions
Community Activities
Weekend Day Trips
Age 18+ Week day Daytime provision
Age 18+ Work experience opportunities
Age 18+ 1:1 Holiday experiences
Age 18+ group holiday experiences
Age 18+ Access to SEND Nightlife (eg disco's/ pub nights etc)
Age 18+ Lifeskills program
Crafting Sessions
What areas are interested in for the member at The Essex Skipper
Hockley
Canvey
Submit
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