Personal Details
Name:*
Address:
City/Town:
County:
Postcode:
Hospital Ward / Prison Wing (if applicable):
Telephone Number:*
Email Address:*
Date of Birth:
Marital Status:
Mental Health Status
MH Section:
Date Section Implemented:
Date of Last MHRT (Mental Health Review Tribunal):
Next MHRT:
Date of Admission:
Index Offence:
When is discharge likely?:
Next of Kin
Name:
Relationship:
Address:
City/Town:
County:
Postcode:
Telephone Number:
Email Address (if known):
General Health
Is the Applicant in general good health?:
Any recurrent / Chronic illnesses?:
Details of any physical disabilities:
Details of Mobility Problems:
Applicant Supervision
Will the Applicant require a Social Supervisor?:
If yes, please provide name:
Job Title:
Address:
City/Town:
County:
Postcode:
Telephone Number:
Applicant's Psychiatric Profile
In order for Cascade Care to consider fully the applicant’s eligibility for assessment, and to process this application promptly, we require:-
Detailed reports of the applicant’s social and psychiatric history, together with details of any criminal convictions.
Details of relevant current and previous medical/surgical conditions and/or treatment, giving details of diagnosis, Treatment and prognosis.
Names of medical practitioners involved and details of any hospital admissions
Medical reports or hospital / prison discharge summaries, if available
Details of any prescribed medication, including details of side effects
Full information for all the above should, wherever possible, accompany the referral form.
Please add any further relevant comments of your own in the following space provided.
Applicant's Social Profile
Please tell us in a few words why you think your applicant would like to live at Cascade Care?:
Does your applicant have any interests/hobbies you think he/she would like help in pursuing whilst living at Cascade Care (please list):
Does your applicant require support around any of the following areas (please tick as appropriate):
Any other areas? (please specify):
For monitoring purposes only, please tell us a little more about your applicant by ticking where appropriate under the following headings:
His/Her Origin
Other (please specify):
His/Her Sexuality
His/Her Religion
Other (please specify):
His/Her Age (Years)
Referral made by
Name:
Job Title:
Organisation:
Telephone Number:
Funding Authority
Contact Name:
Telephone Number:
Thank you for completing these questions. All information received by Cascade Care Limited is treated in complete confidence and in full compliance with the Data Protection Act.
* Required Field
Details of Required Documentation
Thank you for making this referral.
Further information is required as listed to complete the referral process.
We now also require the following information about this applicant:-
History of the prospective Service User including psychiatric history, risk factors, record of any violent or anti-social behaviour, and substance abuse and details of any criminal proceedings and convictions
A clear indication of multi-disciplinary care plans for the prospective Service User including minutes and summaries of previous Section 117 meetings, C.P.A.'s, case conferences and ongoing treatment and therapies.
A full and comprehensive list of contact details for all those retaining responsibility for the Service User post-discharge including emergency and out-of-hours contacts.
Where applicable, a copy of the conditions attached to a conditional discharge under Sections 37/41 of the Mental Health Act 1983.
A supporting psychiatric report from the Responsible Medical Officer (RMO) to include current medication and proposed treatment arrangements in the community.
Please send all available documentation to Alma-Katrina Francis, Referrals & Admissions Manager , at a.francis@cascade-care.co.uk or Fax on 0207 843 5898.
As soon as this information has been received, we will contact you to make arrangements for the applicant's clinical assessment to take place.
Microsoft Word Referral Application Form or 
Adobe PDF Referral Application Form.