Home
My support
In-home support
Daytime and social
Planning your next steps
Services enquiry form
For families
Family zone
Carers representation
Breaking barriers
Our big issues
Our stories
Pioneering programmes
Learning Disabilities Unpacked
Get involved
Appeals
Fundraise
Gifts in wills
Give regularly
Corporate support
Volunteer for us
Minstead Trust Events
Who we are
What we do
Vision, mission, values
Our founding story
Our trustees
Our senior team
Reports and accounts
Contact us
News
Careers and volunteering
Search
Empowering Employment
Social businesses
News
Careers and volunteering
Donate
Home
My support
In-home support
Daytime and social
Planning your next steps
Services enquiry form
For families
Family zone
Carers representation
Breaking barriers
Our big issues
Our stories
Pioneering programmes
Learning Disabilities Unpacked
Get involved
Appeals
Fundraise
Gifts in wills
Give regularly
Corporate support
Volunteer for us
Minstead Trust Events
Who we are
What we do
Vision, mission, values
Our founding story
Our trustees
Our senior team
Reports and accounts
Contact us
Donate
Home
/
New Forest Day Opportunities – Application form
New Forest Day Opportunities - Application form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 12
Full name
*
Name you liked to be called
*
Date of birth
*
Gender
Address
*
Email
*
Phone number
*
National Insurance no
NHS number
Social Worker / Adult Services Information
Named Social Worker
Phone number
Mobile number
Email address
Address
First point of contact regarding your application
Name
Relationship to you
Phone number
Email address
Next
Family Background
Primary carer information
Name
Relationship to applicant
Phone number
Email address
Address
Are you the only main carer?
Yes
No
If no, please provide details
Educational background and work experience
Current or most recent school/college
Name
Provision (day or residential, main stream or specialist, state or private)
Reason for leaving
Next
Have you had any work experience or attended another Day Opportunities?
Name
Work experience or Day Opportunity
Reason for leaving
Attending New Forest Day Service
How many days would you like to attend Day Opportunities? (Monday-Friday)
Are there certain days you would like to come or are you flexible?
Monday
Tuesday
Wednesday
Thursday
Friday
Flexible
Have you got funding in place for attending the day service and transport?
Who will be paying?
Name and email address for invoices
How will you travel to New Forest Day Opportunities?
Activities at New Forest Day Opportunities
Select the activities you would like to try
Woodwork
Ceramics
Art
Craft
Wellbeing (yoga, movement, keep fit)
Animal care
Furzey Gardens and nursery
Grounds maintenance
Forest walking
Vegetable garden
Drama (additional charge)
Cycling (summer only - additional charge)
Next
About you
Tell us about your current daily / weekly routine
Tell us about a good day for you
Tell us about a bad day for you
What is important to you?
What do people like about you?
What are you good at?
What are your interests and hobbies?
What are your goals for the future?
Next
Medical background
Current Doctor (GP)
Name
Phone number
Address
Learning disability or other diagnosis
Details of diagnosis
Do you have any long-standing physical and medical health condition?
Yes
No
If yes, please provide some brief details below
Medication
Medication - do you have any of the following conditions?
Asthma
Diabetes
Eczema
Epilepsy
Hay fever
If you require medication for any of the above conditions please state the medication type below
Will you need this at the Day Service?
Yes
No
Do you self-medicate?
Yes
No
Do you have a history of epilepsy, seizures, fits and/or absences?
Yes
No
If yes please complete the information on epilepsy further down
Do you have sensory functioning difficulties (hearing, sight, smell, taste, touch, pressure, pain or temperature?)
Yes
No
If yes, please describe below
Do you have any mobility needs?
Yes
No
If yes, please describe below
Do you have any special dietary requirements?
Yes
No
If yes, please describe below
Do you have any difficulties when eating and are you at risk of choking?
Yes
No
Do you have any allergies or intolerances?
Yes
No
If yes please fill out the following four questions
What are you allergic to?
Have you ever had an anaphylactic reaction?
Yes
No
Do you carry an Epi pen?
Yes
No
Any other emergency information we should know about your allergy?
Do you recieve any specialist therapy? For example, Speech and Language therapy, Occupational therapy, Physiotherapy or Counselling?
Yes
No
If yes, please give details below and attach any reports
Attach reports here
Click or drag files to this area to upload.
You can upload up to 3 files.
Do you smoke?
Yes
No
Have you smoked in the past?
Yes
No
If yes when did you give up?
Next
Mental Health
Do you have a mental health condition?
Yes
No
If yes please give information below
Do you have any involvement with mental health services?
Yes
No
If yes please give information below
Mental Health Professional Contact name:
Phone number
Next
Epilepsy Questionnaire (please complete if this applies)
Your full name
Date of birth
Epilepsy - Contact Information (in case of emergency) of Parents / Guardian / Guardian / Primary Carer
Name
Relationship to you
Phone number
Email address
Address
Epilepsy - Present Condition
Diagnosis with date
Consultant's name
Address
Phone number
Are you on any anti-epileptic medication (AED’s)
Yes
No
If yes, please specify name of medication and doses
Side effect experienced
Date of last seizure
Seizure type and description of symptoms
How long does the seizure usually last
Possible triggers
Warnings/Aura (if any)
Frequency of seizures
Activities that should be avoided on medical advice
Safer precautions for specific activities
Epilepsy - Contact details
Have you been assigned an Epilepsy or Community Nurse ?
Yes
No
If yes please fill in the details below
Contact name
Phone number
Address
Epilepsy - In case of emergency
Details of emergency medication administered
Rectal Diazepam
Buccal Midazolam
Epilepsy - Hospital admissions
Has hospital admission been required in the past?
Yes
No
If yes, please fill out details below
Frequency of hospital admissions
Date of last hospital admission
Please ensure you attach a copy of the Epilepsy Care Plan with this form.
Click or drag a file to this area to upload.
This will be available from the consultant. You will not be invited for a taster day until this has been received.
Next
Life Skills
Please enter the appropriate support level number for each section below: 1- I am not engaging in this area / 2 - I require full support / 3 - I am achieving this with lots of supervision or prompts / 4 - I am achieving this with light supervision or prompts / 5 - I am achieving this independently
Using speech when I talk with other people
1
2
3
4
5
Comments
Starting conversations
1
2
3
4
5
Comments
Remembering things
1
2
3
4
5
Comments
Remembering things from immediate past
1
2
3
4
5
Comments
Remembering things from distant past
1
2
3
4
5
Comments
Making choices
1
2
3
4
5
Comments
Reading and writing
1
2
3
4
5
Comments
Use of numbers
1
2
3
4
5
Comments
Telling the time
1
2
3
4
5
Comments
I use communication aids
Yes
No
Comments
My preferred method of communication is:
Relationships and social interaction
Please enter the appropriate support level number for each section below: 1- I am not engaging in this area / 2 - I require full support / 3 - I am achieving this with lots of supervision or prompts / 4 - I am achieving this with light supervision or prompts / 5 - I am achieving this independently
Making friends and keeping friendships
1
2
3
4
5
Comments
Recognising different types of relationships
1
2
3
4
5
Comments
Resolving or avoiding conflicts
1
2
3
4
5
Comments
Respecting thoughts and feeling of others
1
2
3
4
5
Comments
Recognising that others have different view points
1
2
3
4
5
Comments
Personal Care and Personal hygiene
Please enter the appropriate support level number for each section below: 1- I am not engaging in this area / 2 - I require full support / 3 - I am achieving this with lots of supervision or prompts / 4 - I am achieving this with light supervision or prompts / 5 - I am achieving this independently
Using the toilet
1
2
3
4
5
Comments
Cleaning yourself after using the toilet
1
2
3
4
5
Comments
Washing your hands after using toilet
1
2
3
4
5
Comments
Continence
1
2
3
4
5
Comments
Self-Appearance / Presentation
1
2
3
4
5
Comments
Care of clothing
1
2
3
4
5
Comments
Domestic skills
Please enter the appropriate support level number for each section below: 1- I am not engaging in this area / 2 - I require full support / 3 - I am achieving this with lots of supervision or prompts / 4 - I am achieving this with light supervision or prompts / 5 - I am achieving this independently
Making a hot drink
1
2
3
4
5
Comments
Making a cold drink (squash)
1
2
3
4
5
Comments
Using the hob and oven
1
2
3
4
5
Comments
Preparing a simple meal
1
2
3
4
5
Comments
Next
Risk assessment - Challenging behaviour
Please describe any past and present behaviours that can affect your everyday life
What are the triggers for these behaviours?
How often do these behaviours occur?
What support strategies help minimize these behaviours?
What might make these behaviours worse?
How do you like to be supported during & after the behaviour?
Do you have a Behaviour Support Plan?
Yes
No
If yes please upload a copy
Click or drag files to this area to upload.
You can upload up to 3 files.
Next
Individual safety
Can you use scissors safely?
Yes
No
Comments
Can you use knives safely in the kitchen?
Yes
No
Comments
Are you vulnerable to abuse?
Yes
No
Comments
Can you safely cross roads?
Yes
No
Comments
Can you safely find you way around when out in the community?
Yes
No
Comments
Do you isolate yourself or become withdrawn?
Yes
No
Comments
Do you neglect yourself?
Yes
No
Comments
Do you like to wander off and not inform people where you are going?
Yes
No
Comments
Are you prone to stranger danger?
Yes
No
Comments
Have you ever used drugs or other illegal substances?
Yes
No
Comments
Do you have a history of an eating disorder?
Yes
No
Comments
Have you ever or do you self-harm?
Yes
No
Comments
Have you ever threatened to commit suicide?
Yes
No
Comments
Do you have an abuse of alcohol?
Yes
No
Comments
Do you have a DOLS/LPS in place? (Deprivation of liberty safeguard)
Yes
No
Comments
Are you concerned about any other issues that may be putting you at risk due to your vulnerability? Consider physical, emotional, sexual and financial - Please describe below:
Please add any other information that may be relevant to attending New Forest Day Opportunities:
Next
Special notes
Have you any objection to being included in any publicity relating to the work of the Minstead Trust including photographs and videos on, for example: website, social media, newsletters, newspapers and television?
Yes
No
Have you any objection to being included in any publicity relating to the work of the Minstead Trust including photographs and videos on, for example: website, social media, newsletters, newspapers and television after you have left the Minstead Trust?
Yes
No
Personal Belongings
The Minstead Trust will not be held responsible for wear and tear, damage, or loss to clothing. Nor will it be responsible for loss, breakage or damage to any watches, mobile phones, radios, personal audio equipment and other similar personal equipment belonging to you, whilst you are attending the Minstead Trust. We recommend that footwear; clothing and personal equipment/belongings are labelled or marked
Insurance
Persons attending New Forest Day Opportunities are covered under the Minstead Trust insurance policy for all its operations, we have employers & public liability insurance; however, we do not cover loss of any personal items that listed in personal belongings.
Declaration
I understand that the information given in this application may be shared with people involved in the admission process and with people who may support you within the Minstead Trust. I have been involved in completing this application and have given my consent for my information to be shared with Minstead Trust. I understand the information in the Special Notes above and have ticked the relevant boxes. I confirm that all information provided is true and correct to the best of my knowledge. I agree to Minstead Trust processing, by means of a computer database or otherwise, any information I provide for the purpose of the admission.
Date
*
Applicant’s signature
*
Name of Person completing form on behalf of applicant
*
Next
What Happens Next
Please submit your application, remembering to include copies of reports from schools, professionals, medical information etc., which may be relevant. Once we have received the application form we will contact you to discuss the next step. We pride ourselves on offering an individual service to all those who access the Minstead Trust, please be assured this application form is the first step to receiving this individual attention ,and any information you can supply helps us towards ensuring the service is right for the applicant.
As part of our admission process we collect information about you on this form and from other reports from professionals. This is so we can make sure that New Forest Day Opportunities is the right placement and service for you. All the information we have about you is treated as confidential and will only be shared with the people who need to know. By completing and signing this form, you are agreeing to us collecting the information and storing it according to the Data Protection Act 2018.
Comment
Submit
Accessibility Tools
