Dear Peer/Service User,
Please answer the questions below to the best of your ability.
We would like you to complete this form with you main care worker, this might be your care coordinator or your psychiatrist.
In this section of the form we would like to know some information about you and your interests, this will help us to match you with a Peer Support Worker.
Your details:
First name:
Surname:
Address:
Post code:
Email:
Telephone:
Date of birth:
How would you describe yourself?
What are your interests/hobbies?
What are you good at doing/what are your strengths?
Where would you like to see yourself in the future?
What do you hope to gain/achieve if you work with a Peer Support Worker? (For example completing a WRAP plan, help with Self Directed Support, setting some goals)
Are you willing to work with male and female Peer Support workers M, F, M&F (please circle)
In this section we would like to know a bit more about your support networks and how you manage your wellbeing.
In an emergency we would need to contact someone, who would you like this to be? This might be a carer, family member, or friend:
Name:
Address:
Post Code:
Telephone:
Relationship to you:
Do you have any other people supporting you from the health care services or other agencies? (Please provide contact numbers)
Care coordinator:
Psychiatrist:
Health care Support worker/Support time recovery worker:
Other important contacts:
If whilst supporting you we have any major concerns about your wellbeing we would need to contact your care team, but we would always discuss this with you first.
Please could you briefly describe your current mental health problems?
Are there any medical conditions which Peer Support Workers need to be aware of (e.g. allergies etc)?
Risk assessment/keeping safe
We will be asking your care worker (person referring with you) to attach a copy of your current risk assessment. Please Discuss this with your care worker and then in the box below describe how we can help manage any areas of risk relevant to work we may do with you on a 1:1 basis or in a group/social situation.
All information will be kept securely; Peer Workers adhere to and are aware of Southern Health NHS Foundation Trust confidentiality policy.
Details of Care worker co-signing this form:
Name:
Agency:
Address:
Telephone:
The information I have given on this form is full and correct to the best of my knowledge
Signed (Peer/Service user) Date:
Signed (Care worker) Date:
Please attach a full risk assessment with this application form.
Completed forms should be returned to:
Emily Hutchings
Peer Support Development Worker
WRAP Team
Southern Health NHS Foundation Trust
Fairways House
Mount Pleasant Industrial Estate
Mount Pleasant road
Southampton
(Please mark the envelope CONFIDENTIAL)
Peer Support Project USE ONLY
RISK ASSESSMENT ATTACHED |
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REFERRAL FORM RECEIVED: |
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WAITING LIST: |
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INITIAL APPOINTMENT: |
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START DATE: |
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ALLOCATED PEER SUPPORT WORKER: |
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