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Urgent Referral Form at Integra Support, Wolverhampton

At Integra Supported Housing, we understand that some situations require immediate attention. Our Urgent Referral program is designed to provide prompt, person-centered support for individuals who need assistance without delay. Whether it’s arranging staffed living, home sharing, or respite services, our team is ready to respond quickly and effectively to ensure the safety and well-being of those in need.

Contact our friendly team of experts to apply today!

01384 982173

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Urgent Referral Request Form

The form should capture essential information to process an urgent referral efficiently:

Referred By:

Date:

Relationship to Service User:

Address:

Contact Number(s):

Your Email Address

Individual Details

Service User Name:

NHS Number:

NI Number:

Current Provider/Living Address:

DOB: required

Gender:

Ethnic Origin:

Post Code:

Legal Status:

Telephone:

Benefits Entitlements:

Social Worker/Care Co-ordinator:

CPN:

Family/NOK:

Consultant:

GP:

Other Significant Contacts:

Current Living Circumstances/Situation:

Mental Health History:

Relapse and Crisis Indicators:

Substance Misuse History:

Daily Living Skills:

Physical Health Needs:

Culture and Faith Needs:

Education, Training and Vocational Needs:

Social and Leisure Needs:

Risk Factors:

Other Relevant Assessment Information:

Current Care Package (or previous package if detained in hospital or prison). Please complete/delete as appropriate:

Shared support hours per day

Shared support hours per week

1:1 support hours per day

1:1 support hours per week

2:1 support hours per day

2:1 support hours per week

Night Support Required

Dedicated

Shared

Safe and Sound Checks Only

No Night Support

On call or other emergency provision

Other

Proposed date for new placement to start/discharge date:

Who will fund the placement?

Has a panel date been set? If so, please give details:

Type of accommodation sought: (You can tick more than 1 option). Required

Sole/singular tenancy

Shared tenancy but with own flat and communal areas.

24 x 7 staffed site

Core & cluster facility (main site staffed 24 x 7, cluster sites are not but can contact staff at main staff).

Other – please give details

Preferred area of placement: (You can tick more than 1 option). Required

Dudley (DY area post codes – Pensnett/Wordsley-Stourbridge/Quarry Bank).

Walsall.

Wolverhampton

Whom should we arrange an assessment with? (Please give contact name and telephone number):

Does anyone else involved in your Client’s care, need to be present for the assessment? If so, please give names and contact numbers:

Loving, caring family spend weekend visiting grandma in her home

Ready to Make an Urgent Referral?

Submit your urgent referral today and ensure fast, reliable support for your loved one.

01384 982173