Access to Service Form

Please fix the following issues before continuing:

PLEASE NOTE: The County Durham Resilience service is a community support service for adults (18 years and over). We 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 support to build emotional resilience and improve mental health predominantly out in the local community or via telephone or virtually. We support adults who live or work in County Durham however please note we do not cover Darlington.

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 always 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

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

Organisation providing details for client (* You can choose that you are coming into the service direct yourself) *

NHS No

First name *

Last name *

Relationship Status

Address *

Letter allowed? *

Yes

Postcode *

Tel *

Mobile

SMS allowed?

Yes

Email allowed

Yes

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 *

My GP isn’t listed

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

Prefer not to say

Language support needed

Yes

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

If yes, please tick all that apply...

Which statement best describes your economic activity?

Main Employment Status

Benefit Claimant

Yes

Not Stated

Unknown

If you are employed, do you work in County Durham

Yes

Prefer not to say

Not applicable

Are you an unpaid carer?

Yes

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

Below we are going to ask some questions about sensory, communication, learning and cognitive differences. Please tick those that apply and leave blank those that do not. We ask the following questions so that we can understand how best to communicate with you and make any reasonable adjustments that may support your care. You do not need a formal diagnosis to request adjustments, and you can choose not to answer these questions.

Do you have a confirmed diagnosis of Autism, ADHD and/or a learning disability?

Are you on the waiting list to be assessed for any of the following?

Do you identify with being autistic, having ADHD and/or a learning disability, but are not currently on a waiting list to be assessed?

Tick this box if none of the above applies to you

N/A

Name of person sending client, telephone number and reason for coming into service *

Referring care professional staff group *

Contacts Email Address *

Appointment Preferences *

Face-to-Face in the Community

Mixture of telephone and face to face in the community

Start with telephone and then move face to face in the community

Telephone

Virtual via MS Teams

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?

Does the individual require any reasonable adjustments to support their engagement with the service? Please provide details (e.g. communication preferences, mobility or sensory needs, learning needs, support with appointments, adaptations to session format or environment).

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 for guidance on suitability

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