Make a Referral

Space Inclusive - Initial Referral

An Initial Referral is our way to gain a perspective from as many different angles as possible on what works best for the individual. Please include details relating to home life, health and wellbeing, dangers and triggers, future wants and wishes, and physical health support needs. This information will help us to ascertain the most suitable Space Inclusive site for your individual and their specific support requirements.

Referrer Details

Client Details

Days preferred/required *(Please check)
Setting preferred/required *(Please check)
Do you require an initial viewing of appropriate site *(please check)
Funding SourceNottingham City
Funding SourceNottinghamshire County
Funding SoureDerbyshire County

Consent and Mental Capacity

Does the person have capacity to make a decision regarding attending Space Inclusive? *
If the person is unable to consent to attending Space Inclusive, is there evidence of consultation in making a best interests decision? *
Please record the names and views of those consulted.

Communication

Support Requirements

Communication needs

Please tick all that apply *

Personal Care needs

Is personal care required? *
If yes, is a particular member of staff preferred?

Travel

Can the client travel independently? *
Does the client have a bus pass? *
If yes, does it include a companion pass? *
Has the client participated in travel training before? *
Please give details of any behaviours of concern(including triggers and strategies/techniques for managing the behaviour)

Health and Fitness

Does the client have mobility issues? *

Additional Information

Matrix Rate (if applicable):

Please specify below which skills and areas of development the client might be interested in exploring further as part of their person-centred support.

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