Clone of Clone of Centa Co Client Application / Referral Form

Centa Co Circle New Service User Application Form. Completing this form does not tie you in to attending every week...it just means that you are registered to attend as and when you wish and we have key information about you so that we can support you better. Please note that this social and arts and crafts group is for autistic women only (18 years+) and all applicants must have an autism diagnosis or a genuine reason to self-diagnose that they are autistic. Autistic applicants with a learning disability may join but their support need for autism must be the greater. The environment will be strictly female only. The standard fee and the fee that we charge local authorities is £30 per session. However, if you are self-funding privately and are on limited funds, the cost is reduced to only £15 per session. Centa Co is a contracted provider of day services for Medway Council and Kent County Council, we can try to apply for funding for you to make it more affordable. It is advised that you see our website for comprehensive information about the group. Estimated time to complete this form is 10 mins (* means information is obligatory; write N/A if a section is not applicable or just leave the section blank)
If you are completing this application form for somebody else, then please give your name and their name

Please note that your first session is free of charge

For more information about the group, either contact us or tap on this link:

https://centa-co.com/autistic-female-group

You can also contact our dedicated AI Agent any questions about the group:

https://centngjlsb.customgpt-agents.com

Want to contact us directly?:

contact@centa-co.com

Tel. 07799 890635
Full name of prospective Service User:*

First NameLast Name
Your full name if you are completing form on behalf of prospective Service User:

First NameLast Name
Your relationship to prospective Service User if you are completing form on behalf of them:
Phone number of prospective Service User: ☎️ (please make sure you provide a contact telephone no. or email address or both):

Area CodePhone Number
Email address of prospective Service User: 📨 (Please make sure you provide a contact telephone no. or email address or both):
example@example.com
Your phone number if you are completing form on behalf of prospective Service User: .: ☎️ (please make sure you provide a contact telephone no. or email address or both):

Area CodePhone Number
Your email address if you are completing form on behalf of prospective Service User: 📨 (Please make sure you provide a contact telephone no. or email address or both):
example@example.com
Address of prospective Service User:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth of prospective Service User (person must be at least 18 years old):*
Gender of prospective Service User (individual must be female):*
Centa Co was established in 2009 has been a contracted provider of day services for Medway Council since 2015 (Supplier Number 03605500) and also has contracts with Kent County Council and the NHS
How did you hear about us?:
Please Specify:

The focus of Centa Co Circle is a on social connection, friendship, feeling safe and included, being yourself without pressure or expectation with arts and crafts offered as a gentle, optional activity to support social interaction
The group meets every Wednesday from 1:45 p.m. till 3:45 p.m. at the Creation Space, Sun Pier House, Medway Street, Chatham, ME4 4HF
Service users may be accompanied by their own one-to-one support worker (female only)
Nature of communication (e.g. direct, delayed processing, needs thinking time) and any special communication requirements?:
Sensory sensitivities (e.g. noise, light, smells, textures):
Social anxiety (e.g. triggers, support needs):
Overloads / meltdowns and known triggers and known effective ways to diffuse and calm:
Masking (e.g. high masking, burnout indicators):
Any past trauma history you would like to mention:
Will the prospective Service User come to sessions and leave them on their own?*
Does the prospective Service user ever go out and about safely in the community on their own? (if not, then they will not be permitted to leave the venue as part of a legitimate risk assessment):*
Main arts and crafts activities prospective Service User likes:
Centa Co Circle autistic women-only service is in accordance with the Equality Act 2010, where single-sex provision is permitted as a proportionate means of achieving legitimate aims, including emotional safety, wellbeing, and meaningful social inclusion for autistic women
From Social Anxiety to Sisterhood 🙂
What would an ideal session be for the prospective Service User, including personal space and social anxiety considerations:
If someone asked what sort of person you are, how you would like to be treated and approached and how you would like to be supported, what would you say?:
There will be a dedicated quiet zone in the room where the sessions take place. If you'd like to switch to that area at any time during the sessions, please let us know. If you want to give us a code word or phrase that tells us you want to do this, then just let us know what that would be (e.g. "I would like a time out please"):
Prospective Service User lives Independently / with Parent / Lives under Supported Living / Lives Under Foster Care or Shared Lives / Other: 🏠
Next of Kin / Emergency contact - name, relationship and phone number:*

Please list if any of these apply as well as autism: Learning Disability / ADHD / Dyslexia / Dyspraxia / Dyscalclia / PTSD / Brain Injury / Other:
GP details incl. Address & Phone No. 🏥
Medical Conditions (e.g. epilepsy with type and triggers; asthma; diabetes):*

Medication Client is on: 💊
Will medication need to be taken during the session? If so, is person able to self-medicate and without prompting:

Does the prospective Service User have any known allergies. If so, what are they, what are the signs an allergy has been triggered and what actions should be taken?:*
Does the prospective Service User have any food allergies, intolerances, sensitivities, or dietary requirements.This includes (but is not limited to) allergies such as nuts, dairy, gluten, eggs, shellfish, soya, sesame, or any other foods or ingredients. Please provide as much detail as possible, including: The specific food(s) involved, The severity of the reaction, Any action required in the event of accidental exposure (e.g. medication, emergency response)*
Behaviours, anxieties or anything else that prospective service user would like us to know about:
Risk assessment information that will help us understand and support you (e.g. phobias; triggers; PTSD; past financial abuse; obsessive behaviour; paranoia; hyperactivity; tripping; coordination; choking; mood fluctuations)
Any area in which prospective client has been deemed to not have Mental Capacity plus details:

Self funding / Council funding to be applied for / Council Funding in place: 💸*
Any contact that will help application e.g. Social Worker at Medway Council / Kent County Council / NHS or other:

Would prospective Service User be accompanied by a one-to-one Support Worker (this person must be female)?:

What outcomes does the prospective Service User hope to achieve by attending Centa Co Circle?(e.g. reduced social anxiety, increased confidence, friendships, creative expression):
Any extra information you'd like to provide:
What would you like Centa Co to do next? e.g. us to contact yourself, the person completing form / you to contact us / us to contact your organisation / us to contact next of kin or a parent / us to contact prospective Service User themself / Centa Co to be contacted PLEASE MAKE SURE YOU'VE LEFT EITHER A PHONE NUMBER OR AN EMAIL ADDRESS FOR US TO CONTACT *
Should be Empty:

Centa Co was established in 2009 has been a contracted provider of day services for Medway Council since 2015 (Supplier Number 03605500) and also has contracts with Kent County Council and the NHS

The focus of Centa Co Circle is a on social connection, friendship, feeling safe and included, being yourself without pressure or expectation with arts and crafts offered as a gentle, optional activity to support social interaction

The group meets every Wednesday from 1:45 p.m. till 3:45 p.m. at the Creation Space, Sun Pier House, Medway Street, Chatham, ME4 4HF

Service users may be accompanied by their own one-to-one support worker (female only)

Centa Co Circle autistic women-only service is in accordance with the Equality Act 2010, where single-sex provision is permitted as a proportionate means of achieving legitimate aims, including emotional safety, wellbeing, and meaningful social inclusion for autistic women

From Social Anxiety to Sisterhood 🙂