Application for Brain in hand license in partnership with the West Cheshire Autism Hub  
Referral Form
Welcome to Brain in Hand.  Please complete the following form to submit the referral. Please complete the form as accurately as possible. Any missing or ambiguous information may result in delays to processing the referral.  Please note * items are mandatory.
*By submitting a referral to Brain in Hand you confirm that you have read, understood and agree to the terms of our Privacy Policy and that you are sharing service users' data with us under an appropriate lawful basis.
Our Privacy Policy can be found at: https://braininhand.co.uk/privacy-and-cookie-policy.



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I confirm that I have read, understood and agree to the terms of Brain in hand's privacy policy and are sharing the service users' data under an appropriate lawful basis.
*First name of the person making the referral
*Last name of the person making the referral:
*Job title
*Email:
contact number
Relationship to user (if applicable)
Which service are you submitting the referral from?
*About the user (person using brain in hand): First name
*Last name:
Preferred name (nick name)
Email address (extremely beneficial for set up)
Alternative email:
*mobile number (please note we will respect the users preferred method of contact)
Date of birth:
MM
/
DD
/
YYYY
Full address including post code:
About the user's supporter: A supporter is someone who can support the user to identify how they will best benefit from Brain in hand.  they usually participate in the set up session and in ongoing support.  Ideally the user will have at least one nominated supporter.  There are two types of supporter: Personal supporter-a family member, partner or friend or professional supporter-a key worker, social worker, mental health mentor, practitioner or anyone with professional support relationship with the user who will be involved with Brain in hand.  
Would the user like to nominate a personal supporter?
Supporter first name:
Supporter last name:
Supporter email:
Supporter contact number:
Relationship to user:
would the user like to nominate a professional supporter?
Clear selection
First name
Last name
email address
Contact number
About the user's emergency contact-please tell us who we can contact if concerns are raised for the user's safety. * Name:
*Phone number of emergency contact:
*Relationship of emergency contact to user:
About the Personal planning sessions: Users have up to 4 hours of personal planning support delivered by a Brain in Hand specialists.  This is usually delivered online using Microsoft Teams. Please let us know if the Brain in hand user has any communication preferences or needs that we should be aware of when arranging or delivering their personal planning sessions.
Please let us know if the service user has an preferences or limitations in terms of when, where we can schedule the personal planning sessions.
Additional support information: Please provide any information that will enable us to support the user effectively.  For example, are there any risk factors in relation to their wellbeing, or their level of engagement with support?  Has the user been supported by any organisations or services that help manage their wellbeing or independence?  Are there any recent or predicted changes to user's support frequency or network?
Using the Brain in hand system: To use brain in hand, a user needs a phone or a tablet that is compatible with the brain in hand app.  They will also need access to the internet via wifi or mobile data.    Please confirm that the following criteria is met by the user: * 1)Able to read and write  in order to be able to update and and maintain their BiH account
Clear selection
*The user has or is willing to purchase a compatible phone or tablet device capable of connecting to the internet, and is confident using it:
Clear selection
*The user has access to, and knows how to use, a computer to a basic level (for example, to visit a web page).
Clear selection
Reasons for referral:
Clear selection
Other: Please provide us with any additional information:
Please indicate what you expect the user to achieve by using Brain in Hand.  What outcomes are you hoping the user achieves as a result of using brain in Hand?
Clear selection
If you answered other to the question above, please specify:
contact preference to arrange meetings
Clear selection
Preferred method of contact
Clear selection
If the option of other was chosen above please specify below:
How many support hours does the person applying for brain in hand currently receive?
Who currently delivers this support?
What is the estimated cost for this support package?
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