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About Us
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My Life Plan Login

LD Referral Form

Step 1 of 14

7%

About Me

Full Name(Required)

First

Date of Birth(Required)

Day

Month

Year

Gender(Required)

Male

Female

Other

Prefer not to say

Please write in the box below

Address(Required)

Street Address Town/City Post Code

Home Phone Number

Mobile Phone Number

Email Address(Required)

My Learning Disability

1. Does your type of learning disability have a name?

If you do not know, leave the box blank.

2. Were you born with the learning disability or did something cause it?

If you do not know, leave the box blank.

My Communication

3. The language I speak and understand is:(Required)

4. How do you communicate?(Required)

Tick as many as you like.

Image for choice number 1

Talking

Image for choice number 2

Signing

Image for choice number 3

Using a communication aid

Image for choice number 4

Pointing and gestures

5a. Do you have any difficulty in communicating?(Required)

Yes

No

5b. What helps you to communicate?(Required)

My Diet

6a. Do you have any difficulties eating, drinking or swallowing?(Required)

Yes

No

6b. What helps you eat, drink or swallow?(Required)

6c. Do you see a speech therapist about this difficulty?(Required)

Yes

No

7. Has your appetite changed recently?(Required)

Yes

No

8. Do you see a dietitian?(Required)

Yes

No

Weight & Appetite

9a. Are you worried about your weight?(Required)

Either putting on too much weight or losing weight.

Yes

No

9b. Why are you worried about your weight?(Required)

Please write in the box below.

Exercise

10. What exercises do you do?

Alcohol

11a. Do you drink alcohol each week?(Required)

Below are some examples of units in common alcoholic drinks.

Yes

No

11b. If yes, how many units do you drink each week?(Required)

12. Do you want help to drink less alcohol?(Required)

Yes

No

Tablets & Medicines

13. Do you take any tablets or medicines that affect your weight?(Required)

Yes

No

My Allergies

14a. Do you have any allergies?(Required)

Yes

No

14b. If yes, what are you allergic to?(Required)

Memory

15. Do you or your carer think there has been a change in your memory?(Required)

Yes

No

My Mobility

16. Are you able to move around easily?(Required)

Yes

No

17. Any comments about your mobility?

18a. Do you use mobility aids?(Required)

This includes wheelchairs, walking sticks, crutches, walkers or a frame etc.

Yes

No

18b. If yes, what mobility aid(s) do you use?(Required)

My Hearing

19. Do you have any difficulty hearing?(Required)

Yes

No

20a. Do you have a hearing aid?(Required)

Yes

No

20b. If yes, do you wear it?

Yes

No

Sometimes

My Eyesight

21. Do you have any problems with your eyes or difficulty seeing things?(Required)

Yes

No

Epilepsy

22a. Do you have epilepsy?(Required)

Yes

No

22b. If yes, do you know what kind of epilepsy you have?(Required)

Any Other Health Conditions

23. Do you have any other health conditions?

If you don’t, leave the box blank.

My Mental Health

24. Do you feel anxious or worried a lot of the time?(Required)

Yes

No

25. Do you feel sad for long periods of time and find it difficult to cheer yourself up?(Required)

Yes

No

26. Do you get angry and shout at people a lot?(Required)

Yes

No

27. Do you ever try to hurt yourself?(Required)

Yes

No

28. Do you see a psychiatrist?(Required)

This is someone who specialises in the prevention, diagnosis, and treatment of mental illness.

Yes

No

29. Do you have support from the mental health team?(Required)

Yes

No

30. Do you have any other comments about your mental health? If not then leave blank

My Care & Support

31. If you have support, who supports you?

If you don’t have any support, skip to forward to question 34.

32. Will they be attending with you?

Yes

No

33. Will they be attending for you?

Yes

No

Family

Name of family carer

First

Family carer’s contact number

Family carer’s e-mail address

Paid Support Worker/Carer

Name of support worker or carer

First

Support worker’s phone number

Support worker’s e-mail address

Social worker (if you have one)

Name of social worker

First

Social worker’s contact number

Social worker’s e-mail address

My Care and Support to Others

34a. Are you a carer for anyone?(Required)

This could be for children, parents or a partner.

Yes

No

34b. If yes, who do you care for?(Required)

Any other information

35. Is there anything else you would like to tell us?

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