P.A.U.L For Brain Recovery

About You

1 First Name *

2 Last Name *

3 How do you like to be addressed?

4 Address line 1 *

5 Address line 2

6 Address line 3

7 Town/City *

8 Postcode *

Contact

Only supply contact information that is safe for us to use. Please supply at least one contact method

9 Mobile Number (no spaces) *

10 Phone Number *

11 Email *

More Information

12 Date of Birth *

13 Gender *

14 Ethnicity *

15 Religion *

16 Your preferred language *

17 How did you hear about P.A.U.L for Brain Recovery? *

18 Type of ABI *

19 ABI Date *

20Goals you want to achieve from attending P.A.U.L For Brain Recovery

Social Activities

Education

Wellbeing activities (including allotment)

Advocacy support

Peer support

Family support

21About your personal circumstances

Can you access P.A.U.L For Brain Recovery services independently?

Can you drive?

Do you require a carer at all times?

Do you need an interpreter?

Challenges

22What challenges are you facing because of your brain injury? So we can better understand how to support you can please list anything you are struggling with.

Support

23Is there a specific type of support you are looking for? Let us know what would make a difference for you – whether it’s resources, services, or just some guidance etc.

Medical & Other Professionals

24 GP Name

25 GP Surgery Name

26 GP Surgery Address Line 1

27 GP Surgery Address Line 2

28 GP Surgery Address Line 3

29 GP Surgery Town/City

30 GP Surgery Postcode

31 GP Phone Number

32GP & Caring Role

Does the GP know about this referral?

Carers need identified?

Does the carer consent to their contact details being passed on to the Carers Information Support Service?

Risk Notes

33Any known risks Please detail risks, including potential for violence. This information is to protect all involved and will help us identify the most appropriate venue for sessions

General Notes

34Please provide any relevant additional information about professional involvement and information that will help the team at P.A.U.L For Brain Recovery allocate the right person to work with you. If there is no additional information, please write – Not Applicable

Self Online Referral Form

Please complete this form to be considered as a referral for yourself. Review our privacy policy here.