Self referral for Brain in hand license in partnership with the West Cheshire Autism Hub
Referral Form
Welcome to Brain in Hand. Please complete the following form as accurately as possible. Please note * items are mandatory.
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I confirm that I have read, understood and agree to the terms of Brain in hand's privacy policy.
*About the user (person using brain in hand): First name
*Last name:
Preferred name (nick name)
Email address (extremely beneficial for set up)
Alternative email:
*mobile number (please note we will respect your preferred method of contact to be filled in later on the form)
Date of birth:
Full address including post code:
A supporter usually participates in the set up sessions and provides ongoing support. A supporter is someone who can support you to identify how you will best benefit from Brain in hand. Ideally you should have at least one nominated supporter. There are two types of supporter: 1)Personal supporter-a family member, partner or friend or 2)professional supporter-a key worker, social worker, mental health mentor, practitioner or anyone with professional support relationship with the user who will be involved with Brain in hand.
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Would the user like to nominate a personal supporter?
Supporter first name:
Supporter last name:
Supporter email:
Supporter contact number:
Relationship to user:
would the user like to nominate a professional supporter?
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First name
Last name
email address
Contact number
About the user's emergency contact-please tell us who we can contact if concerns are raised for the user's safety. * Name:
*Phone number of emergency contact:
*Relationship of emergency contact to user:
About the Personal planning sessions: Users have up to 4 hours of personal planning support delivered by a Brain in Hand specialists. This is usually delivered online using Microsoft Teams. Please let us know if you have any communication preferences or needs that we should be aware of when arranging or delivering their personal planning sessions.
Please let us know if you have any preferences or limitations in terms of when, or where we can schedule the personal planning sessions.
Additional support information: Please provide any information that will enable us to support you effectively. For example, are there any risk factors in relation to your wellbeing, or your level of engagement with support? Have you been supported by any organisations or services that help manage your wellbeing or independence? Are there any recent or predicted changes to your support frequency or network?
Using the Brain in hand system: To use brain in hand, you will need a phone or a tablet that is compatible with the brain in hand app. You will also need access to the internet via wifi or mobile data. Please confirm that the following criteria is met: * 1)Able to read and write in order to be able to update and and maintain your BiH account
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*You have or are willing to purchase a compatible phone or tablet device capable of connecting to the internet, and are confident using it:
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*You have access to, and knows how to use, a computer to a basic level (for example, to visit a web page).
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Reasons for referral:
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Other: Please provide us with any additional information:
Please indicate what you expect to achieve by using Brain in Hand. What outcomes are you hoping to achieve as a result of using brain in Hand?
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If you answered other to the question above, please specify:
contact preference to arrange meetings
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Preferred method of contact
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If the option of other was chosen above please specify below:
If you already receive support, how many support hours do you currently receive?
Who currently delivers this support?
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