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Elim Centre Dolcoath Drive, Camborne, TR14 8RY
Redruth Choice Green Lane Chapel, New Cut, Nettles Hill, TR15 1NX
Riveria house Threemilestone Ind Est. TR4 9LD
Office – 01872 261993
Mobile – 07759663829
Email – [email protected]
This form should be completed as full as possible.
All information provided will be treated in the strictest confidence.
Name:
Address:
D.OB:
N.I. Number:
Contact number:
Name of Organisation/Individual Requesting Referral/Registration
Contact Person:
Address:
Tel No:
Mobile:
Email:
G.P.
--------------------------------------------------------------------------------------------- Are you aware of the service user being involved with any other
relevant services?
Y-N
 Are there any health issues that we need to aware of?
Y-N

Are there any behavioural issues that we need to be aware of?
Y–N

Are there any areas of risk that we need to be aware of? i.e. road safety
Y–N
IF YES, PLEASE PROVIDE FURTHER INFORMATION PRIOR TO TRIAL
DAY AT CHOICE.
FAMILY/CARER CONTACT DETAILS IF DIFFERENT FROM ABOVE.
Name:
Relationship
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Address
Telephone
Fees to be paid by
Cornwall County Council
Individually/Care home
NHS/PCT
Transport to be arranged by
Choice (contact Choice re charges)
Individually/care home
Dept A.S.C
NUMBER OF SESSIONS REQUIRED
DAYS REQUIRED PLEASE CIRCLE Monday Tuesday Wednesday Thursday Friday
Saturday Sunday
SESSION TIMES
9.00am – 3.30 (There may be times, particularly during the summer months,
that we may be late back, we will of course inform you of such occasions.)

DAILY COSTS (Choice day provision) £38.45 a day
a 1.1 support worker

Evening and Weekend Community Linking For Individuals who require extra support

whilst attending Choice we can provide the staff at £15 per hour
Transport Costs arranged and priced individually prior to starting at Choice
£20.00 half day
£15.00 per hour for
.
By signing this form you are agreeing to up to two trial sessions at CHOICE.
If after the trial you wish to attend a Choice centre or engage with the outreach support service
you will be asked to sign an agreement that will inform you of our terms and conditions. If after
the trial you or we decide that Choice is not an appropriate place for you we will not proceed with
the registration and there will be no cost incurred to you.
Signed: __________________________________________________
Name:
__________________________________________________
Date
-----------------------------------------------------------------------------------
Please return form to
Mandy Cross The Manager
CHOICE Elim centre
Dolcoath Drive
Camborne TR14 8RY
Thank you for completing this form.
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