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Thinking about using Brandon Trust support?
Referral FormThis is a form to fill in if you want supportfrom Brandon Trust.
You can ask someone to help you fill it in if you want to.
Please tell us when you are filling this is in.
Date: ……………………………………………..
This form will help us to understand what kind of support you would like and how much.
Things like:
About this form …
Support to live in your own home.
Support to live somewhere with support from staff all the time.
Doing more things for yourself.
Employment training and support to find a job.
Getting involved in things you enjoy.
Please tell us as much as you can about yourself and the support you are looking for.
About you …
What is your name?
What is your address?
What is your phone number?
What is your email address?
What is your date of birth?
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Is someone helping you to fill out this form? Please tell us about them …
What is their name?
What is their address?
What is their phone number?
What is their email address?
If they are not a family member or friend who do they work for?
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Your support …How do you want Brandon Trust to support you?
To live in your own home?
To live somewhere with support from staff all the time?
Employment training or support to find a job?
Getting involved in things you enjoy?
Doing more things for yourself?
Please tell us more: …………………………………………………
Please tell us more: ………………………………………………………………………………………………........
Please tell us more: …………………………………………………………………………………………………....
Please tell us more:………………………………………………....
Please tell us more: ………………………………………………....
What are your support needs?Would staff need special skills or training?Are you interested in getting involved in a project you have heard about?
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Please tell us more about your support …
When would you like your support and how much?
Which days?
What times?
How much support do you need?
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Which town or area is best for you?
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Do you use any other services already? If you do please tell us about them:
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Please tell us if you are sending extra information with this form.
Please tell us if the money to pay for your support is sorted out.
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It might hold things up if the money isn’t sorted out yet.
Thank you for filling out this form.
If you don’t have the money to pay for your support yourself you can speak to your local council to see if they can help.
They will assess you to see if they should pay for your support. They might give the money directly to you to pay for your support. This is called a Direct Payment.
A social worker or care manager will be able to tell you more about this.
Please email it to: [email protected]
Or post it to:Central Referrals, The Park Centre, Daventry Road, Knowle, BristolBS4 1DQ
What happens next?
We will get in touch with you or the person making this referral for you within 1 week of getting this form.
We support people in lots of different ways. The information you share with us will not answer all of our questions.
The person who deals with this form will ask you more questions about what you are looking for.
If we think we can give you the support you are looking for we will tell you within 2 weeks of getting this form.
If someone is filling in this form for you they will tell you how things are going or you can call someone at your local Brandon Trust office.
07464 670211
Contact Andy Bright on:
Or email him at: [email protected]
Brandon Trust, Olympus House, Britannia Road, Patchway, Bristol BS34 5TATel. 0117 907 7200 [email protected] www.brandontrust.org
Registered Charity No. 801571
Brandon Trust is an equal opportunities employer and an equal opportunities provider.
