Review Date of Terms of Reference. The review of the terms of reference for the panel will take place as a minimum annually in December. APPENDIX 3 – s117 Application Paperwork Please ensure Care Plan, Crisis Contingency Plan and S117 Mental Health After Care Plan documents are attached with this application form – the application will not be able to go before the panel until all documents are received fully completed. Submit Application to secure email: xxxxx.Xxxxxxx000@xxx.xxx Section 117 Application Form PATIENT DETAILS Name Gender M / F Date of Birth Ethnicity Care Category MH LD ABI DEM NHS Number AIS No. Brief Description of Diagnosis and Needs MH Act Section of Last Detention S3 S37 S45A S47 S48 Supervised CTO Date of Last Detention Place of Last Detention Employment Status Housing Status Normal Place of Residence Address Originating GP on Admission Name & Address Primary Contact Name Address & Phone Number Responsible CCG Referral Source Name of Unit Being Discharged From PROPOSED NEW PROVIDER DETAILS Name of Organisation Name of Facility Facility Type / Specification Facility Address & Phone No Provider Contact Lead Name Provider Contact Lead Address Phone No PLACEMENT / CARE SCHEDULE Type of Care Planned Length of Care Price Per Day Projected Total Cost Identified Needs to be Met by Placement/Care Package Health Needs Expected Outcomes Designated Support that Provider will be Giving Social Care Needs Expected Outcomes Designated Support that Provider will be Giving Has Patient Been Involved in Choice of Placement/Care? Has Patient Visited Placement? Name of Advocacy Provider Advocacy Contact Name and Phone No Care Progress Reports Requested Initial 3 month Care Plan Quarterly Progress Report Discharge Planning Progress Expected Start Date Care Coordinator Name Care Coordinator Contact details Social Worker Name Social Worker Contact Details CPA Review Date S117 Review Date 3 month post placement visit Date: 6 month placement review Date: For Panel Administration Use: Patient Name NHS Number Date Heard at Panel Panel Attendees Eligible for 117 Yes / No Surrey is Responsible Commissioner Yes / No Appropriately Completed Aftercare and Crisis Plan (need, outcomes, length of placement, client involved and visited placement) Has provision been quality checked? Can provision meet client needs? Care Coordinator/Manager Appointed Review Dates in place 3 month Yes / No 6 month Yes / No
