CheckPoint Enquiry / Referral Form. Name: Address: Date of referral: Date of Age: Male Female Other ……………….. Reason for enquiry or referral: Service request: 1:1 case work Counselling Ethnicity: DISABILITY Please highlight Specific learning difficulty such as dyslexia, No disability dyspraxia or AD(H)D Social/communication impairment such as Physical impairment or mobility issues, such as Asperger’s syndrome/other autistic spectrum disorder difficulty using your arms or using a wheelchair or crutches Blind or have a serious visual impairment Disability, impairment or medical condition that is not listed above Deaf or have a serious hearing impairment Two or more impairments/and or disabling medical You have a long standing illness or health condition such conditions as cancer, HIV, diabetes, chronic heart disease or epilepsy Please give details of any additional requirements or provision to enable them to access the service? i.e. interpreter service, wheel chair access etc. Religion: Unknown/not stated Practising (please say which) Referrer name: Contact details: Referrer relationship to person:
CheckPoint Enquiry / Referral Form. Name: Address: Date of referral: Date of Age: Male Female Other ……………….. Reason for enquiry or referral: Service request: 1:1 case work Counselling Ethnicity: DISABILITY Please highlight No disability Social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder Blind or have a serious visual impairment Deaf or have a serious hearing impairment You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease or epilepsy Specific learning difficulty such as dyslexia, dyspraxia or AD(H)D Physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Disability, impairment or medical condition that is not listed above Two or more impairments/and or disabling medical conditions Please give details of any additional requirements or provision to enable them to access the service? i.e. interpreter service, wheel chair access etc. Religion: Unknown/not stated Practising (please say which) Referrer name: Contact details: Referrer relationship to person:
checkpoint-enquiry-form.docx