ICN Bed Referral Form
Has the patient consented to this referral? This may include assessing medical notes and other personal data in its completion, and for those without recourse to public funds or where otherwise unclear if meeting health bed eligibility, could include discussion and sharing of information with local authority commissioners.
Yes
No
Patient's Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Date of Referral
*
-
Day
-
Month
Year
Date
Patient's Direct Number (if available)
Patient's Gender
*
Male
Female
Non-Binary
Back
Next
CHAIN Number
First Language
*
Additional Languages
Interpreter Needed?
*
Yes
No
Referring Organisation
*
Referrer's Name
*
First Name
Last Name
Referrer's Contact Number
*
Referrer's Email
*
example@example.com
Reason for Referral
*
Current Health Problem
*
Past or other health problems (as much details as is known)
*
Current Registered GP Practice
*
Risk History *** this means information that could impact the safety of those who would be providing healthcare and support during health bed stay, or the safety of the client themselves - by providing an answer below, you confirm that you have performed a risk assessment search of your service records system and any other risk record you may have access to***
*
Any Safeguarding Concerns
*
Care Needs, Details if so
*
Mental Health Support Needs
*
Mobility or Disability
*
Alcohol or Substance Needs
*
Current Housing Situation
*
Rough Sleeping
Hostel
Supported Accommodation
Other
Please give details (such as area)
Has the patient had any previous exclusion from services?
*
Yes
No
If yes please provide details
Current eligibility to public funds?
*
Full eligibility
No eligibility
Unclear eligibility
If Unclear Eligibility please explain why/what is already in place, eg settled status application, whether they have already successfully received housing benefit/share code for housing benefit
If no or unclear eligibility Westminster City Council requests the name of whoever is leading on immigration support
First Name
Last Name
If applicable please indicate which benefits are already in place and being received. (If in place but sanctioned or paused, please provide detail in 'Other')
*
Universal Credit
Personal Independence Payment
Other
Other
Does the client have a known local connection to Westminster?
*
Yes
No
Is the client a verified rough sleeper?
*
Yes
No
What is the move on plan?
*
Submit
Should be Empty: