Suffolk Outreach Pathways – Introduction Form

Introduction Form

Please complete this form to help us assess if we can safely and effectively support you. All fields are relevant to providing person-centred outreach. We only collect what's necessary for assessment, compliance (e.g., insurance, training needs), and safe delivery. By submitting, you consent to us processing this data under UK GDPR for these purposes.
Please provide details about the person who will receive support.
Full name*

First NameLast Name
Preferred name
Age*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number*

Phone Number
Email address
example@example.com
Details of Family or Representative (if applicable)

Please complete this section if someone else is involved in your care decisions.
Name (Family or Representative)

First NameLast Name
Relationship to you
Address (if different)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number (Family or Representative)

Phone Number
Email address (Family or Representative)
example@example.com
Details of the Person Making Contact (if different from above)

If you are completing this form on behalf of someone else, please provide your details.
Name (Referrer)

First NameLast Name
Relationship to the person
Address (Referrer)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number (Referrer)

Phone Number
Email address (Referrer)
example@example.com
YesNo
If No please explain;
Current Living Situation & Support Network
Please tell us about your current living situation and support network so we can understand how best to support you. Feel free to write in sentences or bullet points, you could copy and paste from an existing care plan if you have one.*
Support You Hope to Gain

Please share your support needs and goals.
What type of support do you need from us? (e.g., help with a specific task or activity, mental health recovery, hoarding support, homelessness prevention)*
How often, on which days, and at what times would you like support?
What are you hoping to gain? (e.g., independence, safer home, stable housing)
What works well for you right now? (e.g., strengths, routines that help)
What worries or dangers do you see? (e.g., risks to health, housing stability)
What safety goals do we need to achieve together? (e.g., reduce risks, build support network)
Any known risks to yourself or others we need to be aware of? (e.g., health conditions, behaviours, or location. Please only share what's relevant for safe support)
Funding for Support

Please indicate how the service will be funded.
I will pay privately with my own money/benefitsCouncil-funded direct payment (council rate ~£18.70/hr; top-up may apply)Using a Personal Health BudgetCouncil/other public body will pay
If council-funded direct payment, what is the budget amount (if known)?
If council-funded, how will this happen in practice?
Self-Directed Support

Who is making decisions about your care and how will this work?
Who is contracting the service and making decisions about the care? (e.g., you, family, council)
How will this work in practice? (e.g., decision-making process)
Anything Else We Should Know

Share any other relevant information.
Please share any other relevant information: (e.g., preferences, communication needs, accessibility needs, equipment requirements)
Documents (please attach or bring if applicable)

Tick the documents you are providing and upload them below if possible.
Current risk assessmentSupport or care planCare assessment
Please upload relevant documents (optional)

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Consent and Declaration

Please read and sign below to confirm your consent.
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Introduction Form

Please provide details about the person who will receive support.

Details of Family or Representative (if applicable)

Details of the Person Making Contact (if different from above)

Current Living Situation & Support Network

Support You Hope to Gain

Funding for Support

Self-Directed Support

Anything Else We Should Know

Documents (please attach or bring if applicable)

Consent and Declaration