DCRS Interface - DCRSInterface

Access to Service Form

	PLEASE NOTE: The County Durham Resilience service is a community mental health service for adults (18 years and over). We are primarily an early-intervention service and aim to build resilience within communities in County Durham. This includes; where people feel lonely and isolated, and have experienced mental health difficulties, which includes those impacted by COVID. The service is based upon a recovery framework, and building resilience is at the centre of everything we do. We are here to help people, bridging the gap between services, and helping to improve social wellbeing and mental health. Our service offers lower-level community and psychological support to build emotional resilience and improve mental health predominantly out in the local community or via telephone or virtually. We understand you may have limited information you can provide so we ask that you are able to confirm consent, provide contact details for yourself and the person coming into the service alongside what they are hoping to get support for from the service as mandatory on this form. We appreciate any additional information you are able to provide alongside this however recognise this may not be possible. We require consent of the person coming into the service to be able to move things forward. We will store the information on this form securely. To provide support, we will share details with Tees Esk and Wear Valley NHS and other voluntary and community organisations as part of this multidisciplinary service. We may also share personal information with other NHS and charity organisations to provide further aide and support to the service user. Is the person whose details you are sharing, aware of them coming into our service , and have you gained their consent?
	Please click here for Privacy Statement information - to read details of how our service collects, holds and uses information in accordance with the Data Protection Act.
	Consent to record information *	Yes No
	Any client who comes into the service who develops symptoms of COVID-19 should inform us of this at the point of joining us, first contact and/or prior to any face-to-face contact. * For someone coming to the service direct themselves, please tick to select you are consenting for us to contact
	I confirm the client has given consent for the County Durham Resilience Team to contact them using the details in this form. *	Yes No
	Organisation providing details for client (* You can choose that you are coming into the service direct yourself) *
	NHS No
	First name *
	Last name *
	Address *
	Letter allowed? *	Yes No
	Postcode *
	Tel *
	Mobile
	SMS allowed?	Yes No
	Email
	Email allowed	Yes No
	Primary reason of what you would like support from the service with? (You can state additional needs at the end of the form):
	GP registered *	Unregistered Registered
	GP Details *
	Emergency contact: Relationship to client
	Emergency contact: Name
	Emergency contact: Tel
	Gender	Male Female Prefer not to say Prefer to self identify - please state in notes
	DOB
	Age Band
	Ethnic Group
	Religion or belief
	Which of the following options describes your sexual orientation?	Straight or Heterosexual Gay or Lesbian Bisexual Other Prefer not to say
	Does you gender identify match your sex registered at birth?	Yes No Prefer not to say
	Language support needed	Yes No
	If yes, what language
	Interpreter required?	No - Interpreter not required No - Interpreter was required but did not attend Yes - Another Person Yes - Family member or friend Yes - Professional Interpreter
	The Equality Act 2010 defines a disabled person as "someone who has a physical or mental impairment that has a substantial and long-term adverse effect on their ability to carry out normal day to day activities."
	Do you consider yourself to have a disability according to the terms given in the Equality Act?	Yes No
	If yes, please tick all that apply...
	Which statement best describes your economic activity?
	Main Employment Status
	Benefit Claimant	Yes No Not Stated Unknown
	If you are employed, do you work in County Durham	Yes No Prefer not to say Not applicable
	Are you an unpaid carer?	Yes No
	Carer / Advocate: The patient has confirmed the following person (s) should be included in correspondence (* Please include carer / advocates name and contact number)
	Are you a veteran?	Yes No
	Name of person sending client, telephone number and reason for coming into service *
	Contacts Email Address *
	Any other relevant information you would like to share For example, details around why the person is coming into the service, specific support needs, background information, useful information for arranging sessions etc. If there are several aspects of need please state if signposting / transfer to other services have been done already and if any other support is being provided. Is there any risk to self and/or any risk to others? Have you ever had or currently going through any criminal investigations? Note: Risk does not necessarily exclude people from our service however there needs to be plans to support the client to manage their risk safely with involvement of other appropriate services to work alongside our work
	Any other information? *	None For Information Only Minor Risk/ Alert Risk/ Alert Serious Risk/ Alert
	Notes *
	Any other relevant information you would like to share:
	Access to Service Booklet
	Please refer to the Access to Service booklet via the link to tell us if you would consider the impact mild, moderate or severe	Mild Moderate Severe