Adults (AWD) - AWD Support Application form

MMOV

Adults (AWD) 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
Adult Persons Details

Adult - service users details
Reason for this referral?*
Date of referral:

DayMonthYear
Adults Full Name*

First NameLast Name
Carers Full Name - main contact *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postal CodeCountry
Parent's Full Name - (Second contact)

First NameLast Name
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
E-mail
Other Family Languages:
Adult details/support needs:
Date of Birth:*
Age *
Gender*

MaleFemaleN/A
Class/Form/Yr:
Adults family background /information*
Please add any information which is relevant to this young person e.g. siblings, concerns, etc.
How many hours support has been allocated to support this adult*
Term-time (Eveings and Weekends)
How many hours support has been allocated to during School Holidays? (Non-Term Time) *
Holidays - (Monday to Sunday)
Activities most enjoyed (please list)*
Walking, Shopping, Parks, Playgrounds, Football, Swimming etc.
Special requirements during sessions (please list)*
Food, drink, medication, changing pads etc..
School Attended and Contact?
Health awareness*

Do you have a disabled?Do you have a learning difficulty?Do you suffer from Epilepsy?Do you take medication?AllergiesAutismAspergersADHDOCDMental health issuesOther
What is your ethnic group ?*

White BritishWhite IrishOther White backgroundBlack Caribbean and WhiteAsian and WhiteBlack African and WhiteOther Mixed backgroundIndianBangladeshiPakistaniOther Asian backgroundCaribbeanAfricanOther Black backgroundChineseOther
Adult's family background information (Please tick all that apply)*

Dual ParentsLone ParentLive with Carers/GuardiansIssues of DVChild in Protection (CP)Child In Need (CIN)Other
Level of self- care skills (please tick all that apply)*

Needs help with Personal CareDoes NOT need help with Personal CareNeeds reminders for the toiletToilet training programNeeds pads or nappies changedDoes NOT need pads or nappies changedNeeds help feedingNeeds help dressing
Explain the severity of the diagnosis/ disability and how it is managed *
How can we best support this young person?
Displays anxiety by... (Please tick all that apply)*

Self-harmingShouting/swearingPhysical attackWithdrawalShakingAbscondingSpittingBitingOther
What are the triggers to cause anxiety and how can this anxiety be reduced?*
How can we best support this young person - Is anxiety casued by Noise, Ballons, Colours, Dogs, Other Children etc?
Preferred methods of communication (please tick all that apply)*

Verbal speech onlyVerbal assisted /signalongVerbal assisted / PECS and symbolsVerbal assisted/pointing and leadingOther
Reaction in group settings/ Do they like to be alone/ any sensory support they like?
How can we best support this young person - Feathers, Ballons, Sticks, Reduce Noise, Soothening Colours, Soft Toy etc?
Would it help if we had a copy of the young person's Educational, Health and Care (ECH) plan?

YesNoOther
Type of Support required and Outcomes:

Agreed Outcomes
Male or Female Mentor/Support Worker?:*

Male Support WorkerMale Support WorkerBoth Male and Female Support WorkerNo preferenceOther
Does the young person require:*

1:1 Support2:1 SupportPersonal CareOther
Who has made this referral:

Parent School/ Social Services/ /Head Teacher/Lead Professional
Name of person making the referral:*
Name of Person who has made the referral
E-mail*
example@example.com
Who has made this referral?*

Carer/GuardianSocial ServicesOther
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Address (if different for Above)*

Street Address

Street Address Line 2

CityCounty

Postal Code
I/We consent to Mighty Men of Valour (Valour Youth) holding and using our Personal Data for the purpose of mentor/supporting this young person. Mighty Men of Valour (Valour Youth) will not pass your details to any third parties without your consent.
Do you give MMOV permission to take photographs/ video for Social Story, Personal Achievement etc.

YesNo
Do you give MMOV permission to Provide Support this child:

YesNo
Signature of person making the Referral*

Clear
Signature of Parent/ Carer/ Guardian

Clear
Date of Signature*

MonthDayYear
Date
How will this support funded?
Who will be funding this support?*

Social ServicesCarer/Parent/FamilyOther
How many sessions required?*

Short termLong termOngoingOther
Please check and print referral form before submitting it.
For office use only
Payment Details/ Purchase Orders
Cost of Support per session
Start Referral received

MonthDayYear
Date
Payment Structure
Date Mentoring/ Support Started

MonthDayYear
Date
Should be Empty:

MMOV

Adult Persons Details

Adult details/support needs:

Type of Support required and Outcomes:

Who has made this referral:

How will this support funded?

For office use only