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Yellow Submarine | learning disability

Support for learning disabilities and autism in Oxfordshire

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Adult Profile Form

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Adult Profile Form

For adults

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Adult Profile Form

If you need any support to help you fill out this form or have any questions about the activities we run for adults please contact Sarah.

If there are any questions that you are unsure of the answer to please write TBC.

Step 1 of 4

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About You
Your First Name*
Your Last Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Gender*
Religion*
Language spoken at home*
Your ethnicity*
Do you receive a personal budget?*
- Yes
- No
Who do you live with?*
If other, please give details
Your Address
House number/name*
First line of your address*
Town*
Postcode*
Your Mobile or Home Telephone Number*
Your email address
(If you have one)

Contact Person Details e.g. Parent/Guardian
Contact Person's First Name*
Contact Person's Last Name*
Relationship to you*
Home Telephone Number*
(If they don't have one, just write none)
Mobile Number*
(If they don't have one, just write none)
Email Address*
House number/name*
First line of their address*
Town*
Postcode*
Emergency Contact
Please list two people who can be contacted in an emergency; these should be different to the named contact person.
Emergency Contact 1
Emergency Contact 1: First Name*
Emergency Contact 1: Last Name*
Emergency Contact 1: Relationship to you*
Emergency Contact 1: Home Telephone Number*
Emergency Contact 1: Mobile Number*
Emergency Contact 2
Emergency Contact 2: First Name
Emergency Contact 2: Last Name
Emergency Contact 2: Relationship to you
Emergency Contact 2: Home Telephone Number
Emergency Contact 2: Mobile Number

About your health
Diagnosis - Nature of disability*
GP Contact Details
Name of GP*
GP Telephone Number*
GP's Address
Do you have any allergies?*
- Yes
- No
If YES please give details:*
Do you have a history of seizures or epilepsy?
- Yes
- No
If YES please give details of your protocol:*
Do you have any additional health issues?*
- Yes
- No
If YES please give details:*
Do you take any regular medication?*
(If yes, we will contact you for details)
- Yes
- No
Can you self-medicate?*
- Yes
- No
Do you have any dietary requirements?*
- Yes
- No
If YES please give details:*
Do you drink alcohol?*
- Yes
- No
If YES, how much do you drink on average?*
Do you need any support with continence?*
- Yes
- No
If YES please give details, and explain how staff should support you:*
Do you experience any difficulty with mobility?*
e.g. difficulty climbing stairs or walking long distances
- Yes
- No
If YES, please give details:*
e.g. wheelchair user, walks with assistance
Do you experience any difficulties with communication?*
- Yes
- No
If YES please give details, and explain how staff should best support you:*

How to support you
Do you have any specific likes?*
- Yes
- No
If YES please give details*
Do you have any specific dislikes?*
- Yes
- No
If YES please give details:*
What things are important to you?*
e.g. particular interests, people
Do you require additional support with regards to emotional, behavioural, anxiety or translation needs?*
- Yes
- No
If YES please give details, and explain how staff should best support you:*
Please list anything that causes you anxiety or fear, and how you express it:*
If you become distressed what is the best way for staff to comfort you?*
Are there any areas of your life that you would specifically like us to help you with?
Is there any additional information you would like us to be aware of?
Declaration
I confirm that all of the above information is correct to the best of my knowledge and I understand that this data will be stored under the Data Protection Act 2018 and GDPR regulations. The information may be shared between relevant staff and authorities toensure members can be appropriately supported otherwise it will be treated confidentially. Full details of Yellow Submarine’s policies can be found here: https://www.yellowsubmarine.org.uk/policies/*
Date*
Date Format: DD slash MM slash YYYY
Section Break

Related Pages:

> Activities for adults
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M did not look forward to school holidays as she would be bored. But since joining Yellow Submarine she looks forward to each trip and has had a great summer.

A sibling

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