Wellness Service Referral Form

Thank you for your interest in the Wellness Service.
Please let us know whether you are a professional or a member of the public*

ProfessionalMember of the Public
Wellness Service Professionals Referral Form
The Wellness service aims to help improve and sustain physical and mental wellbeing of people across North Somerset, allowing them to remain as independent as possible in their own home.

The Wellness Service is a free service to residents of North somerset over the age of 18, provided by Access Your Care in partnership with North Somerset Council.

The service operates between the hours of 09:00 and 22:00 seven days a week.

Referrals will be processed between 09:00 and 17:00 Monday to Friday (except bank holidays).

The aims of the Wellness Service are:
- Checking that people are safe and well
- Maintaining people’s independence in the community
- Reducing social isolation
- Signposting people to wider community resources where appropriate
- Exploring the benefits of technology enabled care (TEC)
People will be offered tiered support depending on their desired outcomes.

Tiers of support are as follows:

LOW
- 1 – 3 calls per week
- Free Carelink offer for three weeks and free installation
- Referral for TEC
- Onward community referrals
MEDIUM
- Up to 4 - 7 calls a week
- Free Carelink offer for three weeks and free installation
- Referral for TEC
- Onward community referrals
HIGH
- 8 or more calls a week
- Daily focused tasks
- Free Carelink offer for three weeks and free installation
- Referral for TEC
- Onward community referrals
Criteria for individual being referred:
- Must be a North Somerset resident.
- Must be able to talk on the phone, video call or respond to text
- Be at risk of deterioration in physical or mental health and wellbeing. NB this does not include those with severe and enduring mental health
- Informal carers who are at risk of deterioration in physical and mental health
- Those without care and support including people waiting for domiciliary care in the community
- Those on D2A pathway 1 either in conjunction with them or a step down
- People receiving reablement services either in conjunction or as a step down
- People identified via other community networks and partner agencies
- Those that have suffered bereavement and need reassurance and signposting to other services
Service Contact details:

Telephone: 01275 874861

Email: wellness@accessyourcare.co.uk
Wellness Service Referral Form
The Wellness service aims to help improve and sustain the physical and mental wellbeing of people across North Somerset, allowing them to remain as independent as possible in their own home and communities.

The Wellness Service is a FREE service to residents of North somerset over the age of 18.

The service is provided by Access Your Care in partnership with North Somerset Council.

The service operates between the hours of 09:00 and 22:00 seven days a week.

Referrals will be processed between 09:00 and 17:00 Monday to Friday (except bank holidays).

The Wellness Service can help by:

Checking people are safe and well
Maintaining people’s independence in the community
Reducing social isolation
Signposting people to other community resources, groups, and services
Exploring the benefits of Technology Enabled Care (TEC)
The service will be tailored to the person’s desired outcomes in line with the different levels of contact and support available.

Who can use the Wellness Service?

Must be a North Somerset resident
Must be able to talk on the phone, video call or respond to text
People who have recently returned from hospital
People who are caring for someone else
People recently bereaved
People with physical or mental health conditions that are at risk of deterioration. NB this does not include those with severe and enduring mental health

IF the Wellness Service is concerned for a person’s wellbeing, a referral will be made to Care Connect.

Service User Details
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Postal Code
Date of Birth*

DayMonthYear
Date
Phone Number*
LAS/NHS Number*
Medical History*
GP Practice*
Are you aware of any other professionals involved such as OT's, Social Workers etc?*

YesNo
Please let us know who else is involved*
Is there any TEC in the property?*

YesNo
Please let us know what is in the property*
Is an OT referral required?*

YesNo
Please let us know what the OT referral is for*
Are there any focused tasks? e.g. if the service user needs to be asked if they have had food and fluids*

YesNo
Please specify what focused tasks are required*
Reason for referral and any other relevant information*
What actions would you like the wellness service to take should the person not answer the phone and what timescale would you like to be put into place?*
Emergency Contact for Service User
Name

First NameLast Name
Relationship
Phone Number
Email
example@example.com
Referrer Details
Name*

First NameLast Name
Job Title*
Organisation/Company*
Phone Number*
Email*
example@example.com
Date of Referral*

DayMonthYear
Date

Service User Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

City

Postal Code
Phone Number*
Reason for referral and any additional information*
How did you hear about the wellness service?*
Emergency Contact for Service User
Name

First NameLast Name
Relationship
Phone Number
Email
Referrer Details
Who is making the referral?*

Self ReferralEmergency ContactOther
Please Specify*
Telephone Number*
Have you received the individuals consent to make this referral*

YesNo
Date of Referral

DayMonthYear
Date
What actions would you like the wellness service to take should the person not answer the phone and what timescale would you like to be put into place?*

Thank you for completing our form.

Please click submit to send us your referral.
Should be Empty:

Wellness Service Professionals Referral Form

Wellness Service Referral Form