Asian Women’s Support Service Referral Form



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Dosti
Asian Women’s Support Service

Referral Form


Office Use Only:
Date Received:

Telephone Ref. Taken By:


Acknowledged Date:
Assessment Date:
Worker:




Surname:

Title: Mrs / Miss / Ms




Forename(s):

Date of Birth:




Address:

Email:


Telephone No:





Postcode:




NI Number:




Current Address:
(if different from above)




Arrangements for contacting client:





Consent: has the client’s consent been obtained for this referral? Yes  No 




GP – Name:

Telephone:




Address:
Email:

Postcode:






Carer – Name:

Relationship




Address:
Email:

Telephone:




Has client given consent for the carer to be involved at referral stage?

Yes  No 






Referrer – Name:

Date of referral:




Job Title:



Telephone:




Address:


Email:




Please list any other professionals involved in the client’s care at present:

Social Worker


Tel




Psychiatrist

Tel





Housing Support

Tel





Probation Officer

Tel





CPN

Tel





Care Programme

Co-ordinator



Tel





Other(s) (please specify)


Tel




Preferred Language:

English 

Bengali 

Gujarati 




Urdu 

Hindi 

Punjabi 




Other (please specify)

Ethnicity:

Religion:



Muslim


Hindu


Sikh


Buddhist


None


Others

Did not want to state

Sexuality (Would you like to disclose this?)



Disability:

Speech Impaired 

Vision Impaired 

Hearing Impaired 




Learning Difficulty 

Wheelchair 

Limited Mobility 

Benefits

Are you in Receipt of DLA 
Other (Disability Benefits)  Please specify ……………………………

Residency

British Citizens Asylum Seekers Foreign Students

EU Nationals Refugees Destitute

Indefinite Leave to remain Did not want to state Others

Occupation:

Employed 

Unemployed 

Long Term Sick 




Student 

Other (please specify)

(Please tick all that apply)

Diagnosis (if known)


Medication (if known)

Brief Mental, Social and Housing History:




Please describe client’s behaviour patterns/mannerisms when becoming unwell:




Risk factors, i.e.

History


Of:

Self Harm




Substance Abuse







(please tick all that apply)


Self-neglect




Arson







Violence to property




Violence to providers







Violence to carers



Violence to others







Client’s need and expectations of this service:



Is counseling support required? Yes  No 


Does the client want it? Yes  No 





Signature:





Date:






Please return this form to:
Dosti, Asian Women’s Support Service

Stocks Hill Day Centre

Chapel Lane

Leeds


LS12 2DJ
Tel: 0113 2038893










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