• Valour Youth Application Form

    VALOUR YOUTH

    CWD Support Application form

  • MIGHTY MEN OF VALOUR
    Mentoring |Training | Advocacy | Employment
    PO Box 1417, Croydon, Surrey, CR9 0XJ


    T: 0800 073 1325; M: 07958 770 779; F: 020 8240 7485; W: http://www.mightymenofvalour.org
    Office hours - Monday to Friday: 0800 073 1325 10.30am to 3.30pm

    Out of office hours: 07958 770 779.

    Mighty Men of Valour a Company Registered in England No.05515628
    CHARITY REGISTRATION NO: 1128154

  • Young Persons/ Parents Contact Details

    Young Person/ Parent/ Carer/ Guardian
  • Date of referral:
     - -

  • Parent/Guardian Main Contact Details

    Young Person/ Parent/ Carer/ Guardian
  •  -
  •  -

  • Young Persons details/support needs:

  • Gender*

  • Legal Status

  • Can Service User make all decisions regarding their care and support without requiring a mental capacity assessment?*
  • If No, Does Service User have any of the following powers in place? (Please select all applicable)*
  • Does Service User have any documents relating to their capacity in place? (Please select all applicable)*

  • Is Service user currently under safeguarding?*
  • Does Service user have any known input from any members of the Multi-Disciplinary team (MDT)?*

  • About Me

  • Allergies and Intolerances

  • Does Service User have any food allergies?*
  • Does Service User any medication allergies?*
  • Does Service User have any environmental or contact allergies?*
  • Does Aiden have any intolerances?*

  • Medications

  • Does Service user currently self-administer their medications?*
  • Is Service User prescribed any medication to be taken at specific times?*
  • Does Service User require regular blood sugar monitoring?*
  • Does Service user require regular pulse monitoring?*
  • Does Service User require regular INR tests?*
  • Does Service User receive any covert medication?*
  • Is Service User prescribed prophylactic antibiotics?

  • Communication

  • Is Service User able to communicate verbally ?*
  • Does Service User have any specific communication needs?*
  • Does Service User have any visual impairments?*
  • Does Service User have any visual aids?*
  • Does Service User have any hearing impairments?*
  • Does Service User wear hearing aids?*
  • Is Service User able to use the nurse call bell?*

  • Nutrition

  • Is there a current weight known for Service User?*
  • Has Service User had recent unplanned weight loss?*
  • Does Service User have any special diet?*
  • Does Service User receive enteral feeding?*
  • Does Service User use any oral prosthetic devices (e.g dentures)?*
  • Has Service User had previous choking incidents? *

  • Mobilising

  • Is Service User independently mobile?*
  • Does Service User require assistive aids?*
  • Is Service User 's weight over 158kg?*
  • Does Service User have a history of falls? ?*
  • Does Service User require specific equipment in relation to falls management?*
  • Would Service User require any form of assistance to use the toilet?*
  • Does Service User have a catheter?*
  • Does Service User have a stoma?*

  • Personal Care

  • Does Service User require assistance with personal care?*
  • Does Service User require any specific equipment to meet personal care needs??*

  • Skin

  • Does Service User require any pressure relieving equipment?*
  • Does Service User have any current skin conditions?*
  • Does Service User have any healed pressure ulcers?*
  • Does Service user have any existing pressure ulcers?*
  • Does Service User have any existing wounds?*

  • Sleeping

  • Does Service User have any preferences relating to their sleep needs?
  • Does Service User have a specific sleep pattern?
  • Does Service User currently use bed rails?

  • Social Interaction and Recreation

  • Does Service User have any hobbies/leisure/recreational activities they would like to share?*
  • Does Service User have any known connection to a community group they would like to continue? *
  • Does Service User require support to maintain participation in community groups?*
  • Does Service User require support with their activities?*
  • Does Service User have a preference for group activities or 1-1?*
  • Does Service User have any existing respiratory conditions?*
  • Is Service User currently prescribed Inhalers, Nebulisers or Oxygen therapy?*
  • Does Service user smoke or vape?*
  • Please select*

  • Pain

  • Does Service User have a known history of chronic pain?*
  • Does Service User have prescribed analgesia (medication to relieve pain)?*
  • Regular or PRN?*
  • Is Service User able to verbally express their pain?*
  • Does Service User have a known current infection? (at time of pre-assessment)

  • Infection Prevention and control

  • Does Service User have a known current infection? (at time of pre-assessment)*
  • Is Service User able to self isolate if required for infection control purposes?*

  • Cognition

  • Support worker preference Male or Female Mentor/Support Worker?:*
  • Does Service User have a known cognitive impairment(s)?*
  • Does service User have a known diagnosis of depression?*
  • Does Service User have a known history of experiencing anxiety?*
  • Does Service User have a known history of displaying signs of stress and distress?*
  • Does Service User have a known history of displaying behaviours that may require additional assessment or support?*

  • Advanced Care Planning / End of Life

  • Does Support worker have a DNACPR in place?*
  • If No, Does Service User have ReSPECT plan*
  • Does Service User have an Advance Care Plan or ADRT in place?*
  • Is Service User currently receiving end of life care?*
  • Does Service User have any specific wishes / preferences around end of life care?*

  • Medical History

  • Does Service User have any known past medical conditions?*
  • Does Service User have any other current medical conditions?*
  • Has Service User had any other known surgical procedures?*
  • Does Service User use any other safety equipment or have any implantable medical devices in place?*
  • Is Service User registered disabled?*
  • Do you know a Healthcare Number for Service User ? *
  • Did Service User participate in this assessment?*
  • Is there anything else you wish to document in relation to this assessment?*

  • Who has made this referral:

    Parent School/ Social Services/ /Head Teacher/Lead Professional
  • Who has made this referral?*

  • Child Protection Plan Y/N*
  •  -
  •  -

  • Consent?

    Parent Permissions
  • Do you give Valour Youth (MMOV) permission to Provide Support this child:*
  • Do you give Valour Youth (MMOV) permission to take photographs/ video for Social Story, Personal Achievement etc.
  • Do you give Valour Youth (MMOV) permission carry out personal care routines to your child if required*
  • Do you give Valour Youth (MMOV) permission to give specified prescribed medication to your child:*
  • Where did you hear about our service?*

  • Date of Signature*
     - -
    2 digit month, 2 digit day, 4 digit year

  • How will this support funded?

  • Who will be funding this support?*

  • How many sessions required?*

  • Please check and print referral form before submitting it.

  • For office use only

  • Start Referral received
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date Mentoring/ Support Started
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: