Allocated organisation: (for admin use only):

YOUchoose is a consortium of partner agencies from around the UK, providing personalised one to one support to deaf, deafened, hard of hearing and deafblind (D/deaf) people through the provision of personal assistants - maintaining their independence in the community, developing skills to enable them to live independently/increasing their independence, assisting with personal care, and supporting them to access a variety of services.

Please return the completed form to YOUchoose at: coordination@youchoosesupport.org.uk

1 Service User Details:

Please fill in the boxes below

First name:

Surname:

Address:

Postcode:

Mobile/Telephone:

Email:

Date of birth:

Gender:

Ethnic Origin:

Religion:

Type of Deafness:

First language:

Additional disabilities:

(If Religion or Ethnic Origin are unknown or the person prefers not to say, please state this)

2 Next of Kin:

Give details of next of kin to be contacted in the event of an emergency:

Full names:

Relationship:

Address:

Postcode:

Mob/Tel:

Email:

Do they have power of attorney:

YesNo

3 Additional Useful Contacts:

Add the names and contact details of others who are involved in assessing the care needs at present, so we are able to work together to provide the best service:

Doctor/GP

Name:

Address:

Postcode:

Telephone:

Email:

Social Worker

Name:

Address:

Postcode:

Mobile/Telephone:

Email:

Name of any other organisation(s)

Name:

Address:

Postcode:

Mobile/Telephone:

Email:

Name:

Address:

Postcode:

Mobile/Telephone:

Email:

5 Catchment Areas:

Please select the organisation/area relevant to where the person lives (however if you are looking for support for different areas which are not listed below then please contact us directly):

DeafCOG (East and West Sussex, Brighton)Manchester Deaf Centre (Greater Manchester)Gloucestershire Deaf Association (Gloucestershire)Deaf Smart (Shropshire and the surrounding areas)Action Deafness Community (Midlands)*

*(In addition, Personal Care Support is available)

Confidentiality Policy and Data Protection Act

Consortium members are committed to providing a confidential service and has a full confidentiality policy in place which is available on request.
The personal data collected on this form will only be used for the purpose of processing the referral in accordance with our policy, i.e. for administrative reasons. In addition, statistical (but not personal) information may be shared with funding bodies and the Government for monitoring purposes.
As some of the personal data we have collected is deemed sensitive under the Data Protection Act, your written consent is required. You can provide that by signing below.
Consortium members may contact you on occasions with relevant information.

No details will be passed to any commercial organization.

I understand and agree to the processing of my personal data provided on this form according to the terms outlined above and confirm that all information on this form is correct.

Referral Form

1 Service User Details:

Please fill in the boxes below

(If Religion or Ethnic Origin are unknown or the person prefers not to say, please state this)

2 Next of Kin:

Give details of next of kin to be contacted in the event of an emergency:

3 Additional Useful Contacts:

Add the names and contact details of others who are involved in assessing the care needs at present, so we are able to work together to provide the best service:

Doctor/GP

Social Worker

Name of any other organisation(s)

4 Initial Assessment:

Please complete the next section to give as full a picture as possible:

5 Catchment Areas:

Please select the organisation/area relevant to where the person lives (however if you are looking for support for different areas which are not listed below then please contact us directly):

*(In addition, Personal Care Support is available)

Confidentiality Policy and Data Protection Act