Please fill in this form as completely as you can, as this will help us to deal with your enquiry more effectively. If you need help filling in the form, please contact our helpline on 01206 768797.

ARE YOU COMPLETING THIS FORM FOR SOMEONE ELSE?
☐ Yes (please continue to section 2) ☐ No I am applying for Headway Services myself (please complete section 3 onwards)
How can Headway Essex help, tick all services of interest ☐ Community Support ☐ Day Services ☐ Further Support and Therapies

YOUR RELATIONSHIP TO THE PERSON BEING REFERRED
Your Name ___________________________________	In what capacity do you know the person with the brain injury?
☐ Spouse or Partner ☐ Family member ☐ Friend	☐ Professional ☐ Other (please specify)
Name of your agency (if professional) ________________________________ Address: ________________________________	Telephone No: _______________________________ Email: _____________________________________
Is the person aware of this referral ☐Yes ☐ No IMPORTANT - in order that we can provide support please ensure the person being referred has completed and signed section 8, the declaration and consent form. (Please fill in the rest of this form.)

DETAILS OF PERSON BEING REFERRED
Title: Mr /Mrs/Ms/Miss / Other. _____________ First Name (known as):_______________________ Surname: _______________________________ Current address and postcode: ______________________________________ ______________________________________	Telephone No: ___________________________ Email: _________________________________ Date of birth: ____________________________ Gender: ________________________________

Language and Cultural background (optional) Your answers help us to develop better services. We use them only to ensure our services reflect the backgrounds of the people we support.
Country of origin: ______________________	Can you speak English? ☐ Yes ☐ No
Ethnic or cultural background: ☐ Asian ☐ Black - British ☐ Black – African	☐ Chinese ☐ Mixed – White/Asian ☐ Mixed – White/Black	☐ White – British ☐ White – Irish ☐ Other (please state)
Religion: ___________________________	☐ Rather not say

Details of the Person with Acquired Brain Injury (ABI) who is being cared for
Name of person with ABI: ___________________________ Date of Birth: ___________________ Date of injury: _________________________	Do you have medical confirmation of Acquired brain injury? ☐ Yes - Please provide a copy for our records ☐ No Is the person with ABI aware of this referral? ☐ Yes ☐ No
Cause of Injury: ☐ Road Traffic Collision ☐ Fall ☐ Sport / Leisure Accident ☐ Assault / Violence	☐ Stroke ☐ Hemorrhage (bleed) ☐ Meningitis or Encephalitis ☐ Anoxia/Hypoxia (lack of oxygen)	☐ Tumour removal ☐ Alcohol-related brain injury ☐ Other (please specify)
Relationship to the Carer: ☐ Spouse or Partner ☐ Friend ☐ Family member ☐ Other (please specify)

HOW CAN WE HELP?
What are the current issues/concerns? ________________________________________________________________________________________ ________________________________________________________________________________________
How can Headway Essex help? ________________________________________________________________________________________ ________________________________________________________________________________________

Please supply any other information that you feel is relevant to enable us to support you. ________________________________________________________________________________________ ________________________________________________________________________________________
Would you be able to travel to one of our offices in Benfleet or Colchester to meet with a worker if required? ☐ Yes ☐ No

SUPPORT/SERVICES CURRENTLY IN PLACE
What benefits are in Place? ☐ Child Tax Credits ☐ Employment and Support allowance ☐ Housing Benefit	☐ Income Support ☐ Job Seekers Allowance ☐ Personal Independence Payment	☐ Universal Credit ☐ Working Tax Credits ☐ Other (Please specify)
Social Worker ‘s Name ___________________________ Email: ________________________________________	Telephone No: _________________________________
Doctor’s Name _________________________________ Telephone No: __________________________________	Address:________________________________ _______________________________________
Please provide details of any other agencies that are currently supporting you? (Full name and contact details – if any) ____________________________________________________________________________________
Please provide details of any other Voluntary organisations that are supporting you? (Full name and contact details – if any) ____________________________________________________________________________________

UNDERSTANDING OUR SERVICES
How did you hear about Headway Essex?
☐ Doctor	☐ Hospital	☐ Internet	☐ News Article	☐ Word of Mouth

DECLARATION AND CONSENT TO BE SIGNED BY THE PERSON BEING REFERRED
Headway Essex is committed to protecting your personal data in line with General Data Protection Regulations and in order for Headway Essex to support individuals in relation to their current circumstances, we need permission to obtain, share and hold your personal data both internally between departments and external third parties/ agencies. Please read the attached Privacy Notice which sets out: what personal data Headway Essex processes about you, the reason it processes that personal data, its legal basis for processing that personal data, and how long it will process it for; who to contact in the event that you have any queries relating to your personal data; how we use your information; who Headway Essex may share your personal data with; the extent to which Headway Essex transfers personal data outside the European Economic Area and what rights you have in relation to your personal data, and how to exercise them. ________________________________________________________________________________________________ CONSENT ☐I hereby consent to Headway Essex’s permission to obtain, hold and share personal data in order to conduct its business and provide support whilst using its services. I hereby consent to an authorised Headway Essex employee to act on my behalf and liaise with the appropriate agencies in relation to my current circumstances: Tick all that apply. ☐ Social Care ☐ GP ☐ DWP/Benefit Agency Social Care ☐ Friends/Family ☐ Consultant ☐ Other (Please state) ☐ Hospital/Rehabilitation Unit Information I do not wish to share (please state): ________________________________________________ Person/Agency I do not wish to share information with (Please state): ________________________________ You have the right to withdraw your consent in writing at any time. Signature of person being referred __________________________ Print Name _________________________ Dated: ___________________________

For office use only Client ID: CCG Area: …………………………… Referral taken by: Date: Attach this form to the Assessment Form