Initial Referral & Service User Profile INITIAL REFERRAL & SU PROFILE (QMS-F036-038) Contact Document Ref: QMS-F036-038 (Intake & Profile)Version: 1.0Confidentiality Level: HIGH (Restricted Access)CQC Alignment: Caring, ResponsiveISO 9001:2015 Requirement: Section 7.5 & 8.2 Service User Full NameService User ID NumberReason for completing this form- Select -New Client ReferralAnnual or 6-Month ReviewUpdate to Existing DetailsChange of CircumstancesOperating Local Authority- Select -HaringeyIslingtonWaltham ForestBarnetOtherCare Funding & Financial Arrangements- Select -Local Authority Managed (Direct Commissioning)NHS Funded (Continuing Healthcare - CHC)Direct Payments (Personal Budgets)Self-Funded (Full Cost)OtherSECTION 1: Referral OriginReferral Source- Select -Local Authority / Social Services (Brokerage)ICB / NHS Continuing Healthcare (CHC)Hospital Discharge Team / WardGeneral Practitioner (GP) / Primary Care Network (PCN)District Nurse / Allied Health ProfessionalOther Care Provider / AgencyCharity / Voluntary OrganisationFamily Member / FriendSelf-Referral (Private)Internet Search / WebsiteWord of MouthOtherFunding Local Authority / ICB- Select -HaringeyIslingtonBarnetWaltham ForestEnfieldCamdenHackneyNorth Central London ICB (Covers Haringey, Enfield, Islington, Barnet, Camden)North East London ICB (Covers Waltham Forest, Hackney)Other Local AuthorityOther ICBNot Applicable / Private FundingDate Referral ReceivedStart Date of CareLA/ICB Support Plan Upload ConfirmationPlease confirm that the original LA/ICB Support Plan and Brokerage details have been securely uploaded to the service user's Nourish profile.Yes, uploaded to NourishNo, awaiting documentReason for missing document / Action takenName of Social Worker / Lead CommissionerSocial Worker Contact NumberSocial Worker EmailSECTION 2: Core Service User DemographicsTitle- Select -MrMrsMissMsMxOtherPreferred Name / Known AsDate of BirthNHS NumberHome AddressPost CodeKey Access / Safe Key CodeMain TelephoneCommunication Needs- Select -Clear Spoken EnglishInterpreter Required (Spoken Language)British Sign Language (BSL)Makaton / Keyword SigningNon-Verbal / Uses GesturesHearing Aid(s) / Cochlear ImplantGlasses / Visual AidsAAC Device (e.g., Text-to-Speech iPad)Picture Boards / PECSLarge Print DocumentsEasy Read Format (Pictures + Simple Text)Audio / BrailleRequires extra time to process informationRequires short, simple sentencesSECTION 3: Protected Characteristics & Cultural ProfileGender Identity- Select -MaleFemaleNon-BinaryPrefer not to sayMarital Status- Select -SingleMarriedCivil PartnershipSeparatedDivorcedWidowedPrefer not to sayEthnicity- Select -White - English / Welsh / Scottish / Northern Irish / BritishWhite - IrishWhite - Gypsy or Irish TravellerWhite - Any other White backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - Any other Mixed / Multiple ethnic backgroundAsian / Asian British - IndianAsian / Asian British - PakistaniAsian / Asian British - BangladeshiAsian / Asian British - ChineseAsian / Asian British - Any other Asian backgroundBlack / African / Caribbean / Black British - AfricanBlack / African / Caribbean / Black British - CaribbeanBlack / African / Caribbean / Black British - Any other Black backgroundOther Ethnic Group - ArabOther Ethnic Group - Any other ethnic groupPrefer not to sayReligion / Beliefs- Select -No religionChristian (including all denominations)BuddhistHinduJewishMuslimSikhAny other religionPrefer not to sayCultural or Religious Care PreferencesSECTION 4: Important Contacts & Support NetworksName of Next of Kin (NOK)NOK Relationship to Service User- Select -Spouse / Civil PartnerPartner / CohabiteeParentChildSiblingExtended Family Member (e.g., Grandchild, Niece/Nephew)FriendNeighbourAdvocate / Legal RepresentativeOtherNOK Primary PhoneIs NOK the primary Emergency Contact?- Select -YesNoDoes this person hold Lasting Power of Attorney (LPA)?- Select -NoYes - Health & WelfareYes - Property & FinanceYes - BothLPA Document Verification (Nourish)- Select -Yes, the verified OPG document has been uploaded to the Service User's Nourish profile.No, the document is pending upload.General Practitioner (GP) NameGP Surgery Name & AddressGP Email & TelephonePharmacy NamePharmacy AddressPharmacy Email & TelephoneSECTION 5: "A Little About Me" (Person-Centred Outcomes)My Life HistoryMy Hobbies, Food Preferences and InterestsWhat a 'Good Day' looks like for meWhat a 'Bad Day' looks like for meHow I like to be supportedSECTION 6: QMS Sign-Off & Audit ControlAssessor NamePosition / RoleDate of AssessmentReview Cycle- Select -4 Weeks (Initial Review)3 Months6 Months12 Months (Statutory Maximum)Name of Reviewing Officer / Care ManagerDate of Referral ReviewReferral Outcome Decision- Select -Accepted - Proceed to Initial Needs AssessmentAccepted - Placed on Waitlist (Pending Staff Capacity)Accepted - Pending Funding ApprovalRejected - Cannot Safely Meet NeedsRejected - Out of Catchment AreaRejected - No Staff CapacityWithdrawn by Referrer / Service UserQMS Management Declaration- Select -I confirm I have reviewed this referral profile, verified the provided information, and authorized the recorded outcome in accordance with Mutima Care's admissions policy.Save Record & Proceed
