Quality of Life Intake Referral Form

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If you or someone that you know needs Quality of Life Aid, PLEASE fill out the form below so that we can determine the best way to assist them.

This form is provided with the understanding that A&MWF is not rendering legal, accounting, or other professional advice or service. Professional advice on specific issues should be sought from an accountant, lawyer, or other professional.

QUALITY OF LIFE AID INTAKE REFERRAL FORM

Please note that this information has been gathered to help us provide Your Client with a service that will meet thier needs. The information will be treated in STRICT CONFIDENCE.

Name of Applicant(required)

Your Email Address (required)

Best Contact Information For Your Client(required)

What is the Subject of your inquiry?

How can we help you?

Current Address of Applicant

Phone Number

Height

Weight

Age

Married, Family?

ACCOMMODATION HISTORY AND NEED

Name of Referring Person

Contact Information of Referring Person

Why have You Refered Your Client for Aid?

Where is Your Client Currently Residing?

How long Have They Resided There?

Are They Moving Out, Why?

Has Your Client Been Registered with Local Social Services, Medical, Housing Authorities? Which Ones?

HEALTH HISTORY

Your Client’s Doctor’s Contact Information

Are you aware of any serious physical health problem your client may currently be suffering from or have suffered from in the past?If yes please elaborate.

Has Your Client Ever Suffered from Any Psychiatric illness? If yes, please elaborate.

Is Your Client Living with Any Psychiatric illness at present? If yes, please elaborate.

Is Your Client in Contact with Any Support Agency Concerned with Psychiatric illness or with Any Psychiatric Unit? If yes, please give details.

Is Your Client on Any Type of Medication? If yes, please give details.

Does Your Client have Any Learning Difficulties? If yes, please elaborate.

Have these difficulties been formally identified through the health board disability services? If yes, please elaborate.

PATTERNS OF BEHAVIOUR

Has Your Client Ever Been the Victim of Violence? If yes, please elaborate.

Has Your Client Ever Had an Addiction Problem? If yes, what form(s) has this taken?

Is Your Client Currently Drinking, Using Unprescribed Drugs, or Gambling? If yes, please elaborate.

Has Your Client had Contact with Any Addiction Support Service? If yes, please elaborate.

Has Your Client Had a Criminal Conviction? If yes, please elaborate.

Has Your Client Had Any Involvement with the Probation Service? If yes, please elaborate.

Has Your Client Ever Attempted to Inflict Serious Self Harm? If yes, please elaborate.

Does Your Client Have Any Behavioural Problems? If yes, please elaborate.

Is Your Client Receiving Any Support or Assistance from Any Services for These Problems? If yes, please elaborate.

FINANCIAL SITUATION

What is Your Cient's Main Source of Subsistence? Employment, Unemployment Assistance Benefit, Sickness Benefit, Disability Allowance, Pension, Job Training Allowance, Grant, Other

If Your Client is On a Pension or Grant or Another Source of Subsistence, please state It’s Source, the Amount, Method and When It’s Paid.

OTHER INFORMATION

Is There Any Other Information that You Would Like to Offer?

Give Us Your Self Assessment of The Situation

Please note that this information has been gathered to help us provide Your Client with a service that will meet thier needs. They should not fail to provide information required of them and which is relevant to this application for legal aid/assistance. They MUST provide all documents to us in connection with this application for legal aid/assistance and it is a crime to present information that is false or misleading and they MUST NOT make a false or misleading statement either orally or in writing in relation to this application for legal aid/assistance and therefore declare that all the information they have given is true and correct. The information will be treated in STRICT CONFIDENCE.


I Accept the Aaron and Margaret Wallace Foundation’s Terms of Submission.

4 Responses to “Quality of Life Intake Referral Form”

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