Referral Form

Referred Persons Name:

Date:

Address:

Date of Birth:

Contact number:

Email address:

Referrer’s Name if different to above:

Contact number:

Profession/Relationship with client:

Address:

ABI type: ABI type:TBIStrokeHypoxia/anoxiaOther

ABI Date:

Main goal the referred person wants to achieve from attending P.A.U.L For Brain Recovery: Main goal the referred person wants to achieve from attending P.A.U.L For Brain Recovery:Social ActivitiesEducationWellbeing activities (including allotment)Advocacy supportPeer supportFamily support

Can the service user access P.A.U.L For Brain Recovery services independently? Can the service user access P.A.U.L For Brain Recovery services independently?YesNo

Can the service user drive? Can the service user drive?YesNo

Does the service user require any interpreter? Does the service user require any interpreter? YesNo

GP Contact details: Name: Dr

Address and contact phone number:

Does the GP know about this referral? Does the GP know about this referral? YesNo

Carers need identified? Carers need identified?YesNo

Other professionals involved with the individual (other than GP). Name:

Does the carer consent to their contact details being passed on to the Carers Information Support Service? Does the carer consent to their contact details being passed on to the Carers Information Support Service?YesNo

Profession:

Contact details:

Main reason for involvement of the professional above:

Any known risks Please detail risks, including potential for violence. This information is to protect all involved and will help us identify the most appropriate venue for sessions.

Personal Details about the person being referred - All information provided ensures we can provide the best possible service for you.

Gender GenderMaleFemaleNon-BinaryPrefer Not To SayOther (please state)

If selected other, please state

Ethnicity

Religion

How did you hear about P.A.U.L for Brain Recovery? How did you hear about P.A.U.L for Brain Recovery?MediaSocial MediaFriendHospitalGP

Your preferred language:

If making a referral: If making a referral: please tick this box as a signature mark to confirm that you have the referred persons consent to make this referral.

Date: