Clone of Discharge PHB referral

Returning Home: Essentials PHB referral

(Discharge Team only Referral)
Eligibility criteria
This referral form is for Inpatient Discharge Team only - City and Hackney (Centre of Mental Health)

To receive a PHB, please confirm the individual is;
- Resident of City and Hackney
If you like to discuss your PHB referral before submitting it, please contact Bonnie.studd@nhs.net or call via NHS teams.
Any issues submitting your referral, please follow up via email to Phb@corearts.co.uk or call 0208533500.
Please tick this box to confirm that the person you are referring meets the eligibility criteria**

Yes, I understand - tick to continue
Please check the box if you understand that by submitting this personal information you are consenting to Core Arts holding and using it in accordance with our privacy policy.*

Yes, I understand
Referrer details
Full Name*

First NameLast Name
Telephone number*
Please enter a valid phone number.Format: 00000000000.
Email address*
example@example.com
Borough*
Team*
Is there a clinical team/ assigned to the PHB holder as part of discharge planning and ongoing carer and support? Please specify:
Name

First NameLast Name
Team
Email address
example@example.com
PHB holder
Name*

First NameLast Name
NHS number*
Please imput number in this format 111-111-1111
Date of birth*

DayMonthYear
Date
Email address*
example@example.com
Telephone number*
Please enter a valid phone number.Format: 00000000000.
Address in the community*
Postcode*
Borough
Current Ward
Current status
When was the previous admission for this PHB holder (outside of current admission)?

3-6 monthWithin the last yearWithin last 2 yearsNot been hospitalised in over 2 yearsNot been hospitalised in over 5 years
Is this client a frequent attender of NHS services?

YesNo
PHB Holder demographics
Gender*
Ethnicity*
Sexual orientation*
Is the service user on s117 aftercare?*
Accommodation status on discharge*
Employment status*
Have you been in the armed forces?*
The Personalised Mental Health Recovery Goal
The starting point to any PHB request is the recovery goal.

In you answer below please offer the following;
- What is the mental health recovery goal?
- How does the item/ activity requested support that goal?
Please note:

*You can personalise an 'New accommodation starter pack' by choosing the specific items for purchase, otherwise the PHB team will provide the essentials and choose from what is in stock/ available and value for money.

* If you choose an 'other' items please send the specified website links with the application.
Summarise the mental health recovery goal and how the PHB will support that goal:*
Please explain how this will support their recovery and improve discharge timeframe
Please choose from the list below:

Kitchen utensils – £30Plates/Cups/Cutlery – £35Microwave – £60Toaster/Kettle – £25Bed + Mattress – £215Bedding – £25Citizen card ID – £30Keys/Locks replacement – £150Oyster cards/Credit – £30Smart phone (Stay connected) – £150Other
If the item you need is not listed above, please add it below with a web link where it can be purchased
Please provide the exact item requested for 'Other'
Total Request - please state the total request from the amounts above (>£250)
Please note - any requests over £250 will require approval from the ELFT PHB team and may delay the process timeframes
Please select the main area this request relates to:*
Please select any other additional areas that are support by this request (optional):
Please select an outcome measure - you can use existing scores from the most recent DIALOG+ plan*
DIALOG+ monitoring

1 – Totally dissatisfied

2 – Very dissatisfied

3 – Fairly dissatisfied

4 – In the middle

5 – Fairly satisfied

6 – Very satisfied

7 – Totally satisfied
How satisfied are you with your mental health?*
How satisfied are you with your physical health?*
How satisfied are you with your job situation?*
How satisfied are you with your accommodation?*
How satisfied are you with your leisure activities?*
How satisfied are you with your relationship with your partner/family?*
How satisfied are you with your friendships?*
How satisfied are you with your personal safety?*
How satisfied are you with your finances?*
How satisfied are you with your expression of identity?*
How satisfied are you with your substance/ alcohol use?*
How satisfied are you with your medication?*
How satisfied are you with the practical help you receive?*
How satisfied are you with your meetings with mental health professionals?*
Approx bed days saved with access to PHB*
How will the PHB facilitate discharge from hospital?*
PHB request- Approval

Please note the maximum amount of funds are £250 without managers approval and the review is required - please specify above the clinician who can review the budget or if it needs to be allocated to the ELFT PHB team.
Is the request over £250?*
Any requests over this will require ELFT PHB lead approval.
Ensuring PHB Item is received effectively
Where should the item be delivered to? (please state a named person, preferred timings and any communication required)*
Additional information for the PHB team or ELFT PHB lead?
Feedback and improvements
Feedback helps us to learn what is working well and what can be improved.
Is the PHB Holder referred happy to be contacted by a member of the ELFT PHB team to share more about your PHB experience?*
Should be Empty:

Returning Home: Essentials PHB referral

Eligibility criteria

Referrer details

PHB holder

PHB Holder demographics

The Personalised Mental Health Recovery Goal

PHB request- Approval

Ensuring PHB Item is received effectively

Feedback and improvements