Navigator Programme

-The Triple A Navigator Service is a programme of individually tailored one-to-one mentor support. A Navigator peer mentor is matched with an autistic adult to help and support them to work towards self-set goals. The aim is to steer and support individuals towards a safe and positive life; building on strengths and navigating a path towards achieving their goals.

Please complete this form if you are autistic, live in Cumbria and would like to work 1:1 with a Triple A Navigator mentor.

This form is designed as an initial point of contact to collect your information as you seek to access services offered by Triple A (an autism charity based in Cumbria). This form can also be used by other professionals or by family members to make a service referral on your behalf, with your consent.
All information collected by the Triple-A will be carefully stored to protect each person’s personal information.
If you have difficulties completing this form, please text 07354564045 or email andrew.millburn@tripleaproject.org.uk for additional help or assistance.
We will contact you using the contact information you provide on your form to discuss how the Triple A team might work with you, or to help signpost you to another organisation that might be more appropriate for meeting your specific needs.

Please note that the Navigator Programme:

– is not designed as an emergency response
– is not a free service. There is a fee. It can either be self-funded, or funded by adult social care.

We expect a navigation to last between 1 to 2 hours each week. More hours can be arranged.

Name *

Date of Birth *

Address *

Postcode *

Email Address *

Telephone Number *

Preferred Method of Contact *

Who are you referring to the Navigator Programme? *

Yourself
Somebody Else

If you are making a referral on behalf of the individual, please identify which organisation, if any, you are making the referral from.

Emergency Contact Name *

Emergency Contact Telephone Number *

Emergency Contact Relationship to You (Parent, Spouse, Partner, Service User) *

Name and Location of GP Practice *

In case of emergency only.

Have you received a diagnosis of Autism? *

If you have not yet received a formal diagnosis of Autism, are you or the person you are referring currently being assessed for a diagnosis of Autism? *

Current living situation: Please tick the box below that best describes your current living situation or the person you are referring *

I live alone
Parent/s or family
Friends
Other

Are you currently receiving support? *

If yes, please give details:

Do you have a social worker? *

Do you have a Health & Wellbeing Coach? *

Have you had a Care Act Assessment? *

Yes
No
Don't Know

How do you think Triple A can help you? *

How is this place to be funded? *

Self-funded
Direct Payments
Social Care Fund
Other

If other, please specify:

Are there any specific goals you wish to achieve whilst working with Triple A? *

Yes
No
Not Sure

If yes, please state what these are:

Triple A Navigators who are working with you may require to speak to other agencies on your behalf. This can only be done with your permission. Please can you tick which on the list you are happy for us to contact: *

Social Services
Police
Specific Supporter or Carer
Mental Health Worker

Confirm (By ticking this box; you are agreeing to Triple A using your information to help determine how Triple A might work with you) *

Tick this box to sign the form

Privacy Notice:

Your details will be kept in accordance with Data Protection Act 2018 and the GDPR (General Data Protection Regulation) and will be held securely and confidentially