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Make A Referral
Before making a referral please read our ‘
Referrals – Frequently Asked Questions
‘
Step
1
of
6
- About You
16%
Please provide the following information.
This will be stored securely & not be shared with third parties. See our
privacy notice
for more info.
Name
*
First
Last
Your Role
*
Parent
Social Worker
Advocate
Community Nurse
Care Manager
Reason for Referral
*
Email
*
Enter Email
Confirm Email
Phone
*
Type of service required
*
Family sized homes with support
Clustered single occupancy with support
Single occupancy with support
Support Without Accommodation (Green Light Go)
Name
First
Last
Date of Birth
*
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Legal Status
*
e.g. Guardianship Order, Detained, N/A
Does the person have a learning disability?
*
Yes
No
Diagnosis
*
Autism
Autistic Spectrum Disorder
Asperger Syndrome
High Functioning Autism
Other
Please provide details:
*
Name of person we should liaise with regarding the person
*
First
Last
Email of person we should liaise with
*
Telephone number of person we should liaise with
*
Please outline any significant incidents and the reason for referral to Green Light
Challenging Behaviour/Risk
To your knowledge has any of the following ever been noted in relation to the individual being referred?
Aggression - threatened, verbal or actual
Yes
No
Destruction of Property
Yes
No
Self-harm/self-injurious behaviour
Yes
No
Absconding - leaving support/supervision
Yes
No
Fire setting
Yes
No
Inappropriate sexual behaviour
Yes
No
Forensic history
Yes
No
Use of weapons
Yes
No
Attempted suicide
Yes
No
Paranoia/Psychotic episodes
Yes
No
Subject to POVA proceedings (protection of vulnerable adults)
Yes
No
On sex offenders register
Yes
No
Self-neglect
Yes
No
Refusing treatment/support/intervention
Yes
No
Epilepsy
Yes
No
Previous admissions to psychiatric hospital/s
Yes
No
Pica (ingesting inedible objects)
Yes
No
Risk to the general public
Yes
No
Risk to children
*
Yes
No
History of aggression towards children
Insomnia/sleep disturbance
Yes
No
Noisy
Yes
No
Threats to kill
Yes
No
Support currently required
Approximately how much support is needed at present
Night
*
Less than 1:1
1:1
2:1
More than 2:1
At home
*
Less than 1:1
1:1
2:1
More than 2:1
In the community
*
Less than 1:1
1:1
2:1
More than 2:1
Other needs
Waking night support needed?
Yes
No
Can live safely with others?
Yes
No
Can manage stairs independently?
Yes
No
Are there any safety risks or environmental risk factors you would like to share with us?
e.g. need to monitor access to knives, matches, etc.
Any other points you would like to share
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