This service is for people identified by Cardiff Council Adult Services as age 18 years and over who have care and support needs for which Cardiff Council is commissioning a care and support package to meet their agreed outcomes, who are ordinarily resident in the city of Cardiff or whose normal residency is within the Cardiff area.

Referrals will only be accepted by The Friendly Trust from Cardiff Council Adult Service Team Social Workers.

To avoid any delays in providing financial advocacy and support to vulnerable citizens, the referral form must be completed in full to allow the service to commence.

Where the referral form asks for mandatory fields* to be completed, but is missed, the referral form will be returned for completion. The Social Worker is required to fill in all fields within this referral form.

About the Referring Social Worker

Date of Referral *

Referring Team *

Name of Social Worker Making Referral *

Email Address of Referring Social Worker *

Information About the Individual Being Referred to The Friendly Trust

CareFirst / Eclipse Number *

Paris number *

Contact Details:

Full Name of the Referred Individual *

Full Address, Including Postcode, of the Referred Individual *

If the Individual has lived at the above address for less than 3 years, please record previous address *

Home Telephone Number *

Mobile Telephone Number

Email

Personal Details

Date of Birth *

National Insurance Number *

GP Name and Practice Address (Including Postcode) *

Living Situation *

• Lives Alone
• Lives in a Residential Care Home
• Lives in a Nursing Care Home
• Lives with Family
• Lives in Supported Living
• Homeless

Details of Next of Kin / First Preferred Contact

Other People Involved in Individual's Life (Family / Carer / Friend / Advocate)

Relationship *

Name *

Address *

Telephone Number *

Email Address *

Details of Second Preferred Contact

Relationship

Name

Address

Telephone Number

Email Address

Summary of the Referral

Please Identify the Reason for the Referral *

Is the Referral for a CHC Patient? *

• Yes
• No

If "Yes", please do not go any further with this referral and refer to the Health Board.

Has a Capacity Assessment Been Completed? *

• Yes
• No
• N/A

Has a Best Interest Assessment Been Completed? *

• Yes
• No
• N/A

If not, do not proceed with this referral until it has been completed.

Type Of Financial Advocacy Required

e.g. Appointee / Deputy / COP / Advice / Multi-services

Health & Safety

Please log any special precautions that need to be taken before The Friendly Trust Officer(s) is to contact or visit the referred person *

Authorisations / Approvals

All referrals must to be authorised by an Adult Service Team Manager for approval of service.

Has Authorisation been approved by your Team Manager? *

• Yes
• No

If not, please do not proceed, and seek authorisation.

Name of Team Manager *

Team Manager's Email Address *

Date of Authorisation *

Privacy Notice *

• Please tick to confirm you have read and agree to our Privacy Notice which can be found below.

Submit

For the avoidance of any delays in providing a service to your client(s), please review your referral form, as The Friendly Trust will not accept any referrals if this referral form has not been completed in full.

Privacy Notice