The Cart Shed: Agency Referral Form

PLEASE READ PRIOR TO SUBMITTING A REFERRAL

Mobility

We are based outdoors in a woodland environment and as such the ground can be uneven, slippery and there can be trip hazards such as tree roots. Our environment may therefore not be suitable for those with poor mobility or poor balance, or those that need certain types of walking aids such as rollator frames. We have open fires on site, so are cautious about accepting referrals for individuals that experience falls or seizures. There is a walk of about 100m from the car park to the woodland site that individuals need to be able to manage.

There are composting toilets on site that are on raised platforms with four 6” steps to access, so individuals need to be able to manage steps independently in order to be able to use our toileting facilities.

Transport

We offer free transport from designated pick-up points in Hereford, Leominster and Kington only, so individuals need to be able to get to one of these pick-up points in order to be able to use our transport. They also need to be able to get on/off of the transport safely and independently.

Level of Support

We endeavour to support as many people as we can, and all referrals are considered on an individual basis. However, there are some individuals we are unable to work with due to the nature of our environment, our staffing levels, or the risk some individuals may pose to others, especially in relation to the children and young people we have on site as part of our Young Cart Shed provision.

As a Tier 1 mental health service, we cannot work with:

· Individuals in mental health crisis, especially if they are not receiving support elsewhere.

· Individuals that are aggressive or violent and pose a risk to our team or to other participants.

· Individuals presenting with predominantly behavioural issues.

· Individuals that pose a risk to children or young people.

· Individuals with a history of sexual offending.

· Individuals requiring 1:1 support on site.

· Individuals with complex physical health needs that require a multidisciplinary approach.

Please be aware that for anyone that is being supported by Probation services, we require a full risk assessment from Probation at the point of referral so that we can make an informed decision as to the suitability of that individual for our service. We can only consider those that Probation has assessed as low risk to others. Without this risk assessment information, the referral will be rejected as incomplete.

Are you completing this form for:

Someone Under 18Someone 18 or above

Contact Details of Person Registering with The Cart Shed for a Course

Name and Date of Birth

Title

First Name

Middle Name

Last Name

Date of Birth

Gender

Preferred Pronoun (optional)

Parent Contact Details

Title

Parent First Name

Middle Name

Parent Last Name

Personal Email

Home Phone (Landline numbers only)

Mobile Phone

Preferred Method of Contact

Relationship (Parent, Guardian etc)

Address

Mailing Street

Mailing City

Mailing County

Mailing Postal Code

Email and Phone

Personal Email

Home Phone (Landline numbers only)

Mobile Phone

Preferred Phone

Preferred Method of Contact

Preferred Method of Contact - Other

GP Details

GP Surgery Name

GP Surgery Postcode

GP Name

School Details

School Name

School Postcode

Point of Contact at School:

Transport Details

Assistance Required getting to/from The Cart Shed

If yes, please indicated preferred pick up point below

Emergency Contact Details

Title

First Name

Last Name

Home Phone (Landline numbers only)

Mobile Phone

Relationship (friend, partner etc)

Armed Forces and Blue Light Community

Armed Forces Connection

Currently ServingVeteranFamily of Serving or Ex-serving Member

Do they currently work for the Blue Light community? Emergency services, NHS, social care sector and armed forces (Please go to https://www.bluelightcard.co.uk/ to see who is included)

YesNo

Which sector do you work in?

Reason for Referral

Reasons For Referral / Needs Identified

Relevant Background Information

Risk Assessment

The more information you can provide us with, the quicker and easier it is for us to screen the referral, incomplete information will mean that we will need to pass the referral back to you.

Please include information around:
Risk to self or others including children
Risk of self neglect
Risk of drug and/or alcohol misuse
Behaviour Issues

Risk Assessment

Additional Documentation

Where relevant and possible please attach copies of EHCP’s, CPA’s, Crisis Plans, Care Plans and any other assessment or reports.

Referrer's Details

Title

First Name

Last Name

Job Title

Organisation Name

Contact Work Number

Add Another Contact Number

Contact Work Mobile Number

Preferred Method of Contact

Preferred Method of Contact - Other

Address

Mailing Street

Mailing City

Mailing County

Mailing Postal Code

Voluntary Contributions

Feedback consistently shows how highly valued our services are by everyone who takes part. As a charity, The Cart Shed relies on fundraising to support people who are not eligible for social care funding to attend our sessions.

We therefore invite participants, where they are able, to make a voluntary contribution towards the cost of their course. Any amount is welcome, and there is no expectation or requirement to contribute. If someone is unable to give, even a small amount, they are still very welcome to be referred and take part, access to our service is never dependent on making a donation.

After enrolment, participants will receive clear information on how they can contribute if they wish to do so. Please ensure this is shared with your client so it is understood in advance and comes as no surprise.

Please check this box to confirm this information has been shared with the client.

Data Protection

The information that is shared with The Cart Shed during the referral process is requested in order to enable provision of appropriate occupational therapy assessment and intervention. It will not be utilised in any other form than for the purpose for which it is collected. If it should become beneficial or necessary to share information with other healthcare professionals, social or welfare organisations this will be done in compliance with the Information Commissioner’s Office GDPR Regulations 2018. All information collected will be held securely.