Care and housing referral form

Your referral

Anything in square brackets still needs an answer. Send the same referral to every provider so you can compare replies fairly — then log who replied and when.

REFERRAL — CARE AND/OR HOUSING SUPPORT
Prepared by the family. Please acknowledge receipt and say yes or no within 10 working days.

1. WHO THIS REFERRAL IS ABOUT
Initials: [P's initials only]
Age: [age]
Current placement or home: [where P lives now, and who provides support]
Legal framework: [e.g. Court of Protection welfare application, deputyship, DoLS, s117 aftercare, Mental Health Act]

2. WHAT WE ARE LOOKING FOR
Type of service: [supported living, residential care, shared lives, own tenancy with care, respite, outreach]
Preferred area: [town, borough, how close to family]
Needed by: [date or timescale]
Property requirements: [ground floor, own bathroom, garden, single occupancy, no shared kitchen, adaptations, wet room, hoist]

3. NEEDS AND DIAGNOSES
Diagnoses and relevant history: [autism, learning disability, epilepsy, mental health, PTSD]
Communication: [speech, AAC, Makaton, processing time, how P shows yes and no, how P shows distress]
Sensory profile: [noise, light, touch, smells, what helps regulate, what to avoid]
Health and medication: [epilepsy protocol, PEG, allergies, medication, health passport]
Behaviour that services must understand: [triggers, early warning signs, what works, what makes it worse, any restrictive practice we do not consent to]

4. SUPPORT PACKAGE
Support hours sought: [e.g. 1:1 waking day plus sleep-in, or 2:1 for community access]
Staffing profile: [gender of staff, consistency, small team, Oliver McGowan trained, PBS trained, autism-specific experience]
Nights: [sleep-in, waking night, none]
Daytime and community: [college, work, activities, transport]

5. FUNDING
[Council Adult Social Care, NHS ICB Continuing Healthcare (CHC), jointly funded package, s117 aftercare, direct payments, Housing Benefit / Universal Credit housing element — include assessment, decision and review dates if known]

6. PROFESSIONALS INVOLVED
[social worker, care manager, ICB commissioner, SALT, OT, psychiatrist, solicitor — name and email for each]

7. WHAT MATTERS TO P
[P's wishes, routines, relationships, interests, what a good day looks like]

8. WHAT WOULD NOT WORK
[shared living, large services, out-of-area, high-noise settings, agency-only staffing]

9. FAMILY CONTACT
[your name] — [relationship to P]
Phone: [phone]   Email: [email]

PLEASE REPLY WITH
a) whether you can meet this support package, b) availability and timescale, c) your indicative weekly cost and what it includes, d) your latest CQC rating and report date, e) staff training relevant to the needs above, f) how you involve family in reviews.

Note from the family: we use initials only in the first referral to protect privacy. Full details follow once you confirm interest and a lawful basis for sharing is in place.

Looking for providers to send it to? Use the directory for care and housing providers, and contacts for your council and ICB.