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Date of referral: xx/xx/xx |
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Is this referral for: ☒ ADULTS Mental Health Service ☐ Or OLDER ADULTS Mental Health Service, ☐ Or patients with Suspected Dementia (please ensure a relevant memory screening test has been carried out e.g. MMSE, GPCOG) ☐ Or Psychosis (Early Intervention) and At Risk Mental States
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Patient details
Name: <Patient Name>
DOB: XX/XX/XX NHS number: <Patient number>
Address: <Patient Address>
Telephone: <Patient Contact Details>
Ethnicity: British
email : <Patient Contact Details>
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Carer or next of kin details –
Mr/ Mrs/ Ms/ other
Name:
Relationship to patient:
Address:
Telephone:
Do appointments need to be arranged via a relative or carer? Yes ☐ No ☐ (If yes, please ensure that details are provided) |
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Referrer details
Name: <Your name>
Role: <Your Details>
Email: <Your email address>
Contact number: <Your telephone number>
Date patient last seen by referrer: XX/XX/XX
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GP details (if different from referrer details)
Name -
Address - Contact number/email:
Date patient last seen by GP: |
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Please list your reasons for referral or provisional working
diagnosis: Following further assessment and treatment, it is felt that this client should be referred to secondary care services. Client presents with symptoms consistent with… (give summary of presenting issue)
Due to the complexity, the severity and the enduring nature of the presentation we feel that his treatment would be better suited to a secondary care intervention as this falls outside of the remit of primary care, as such we are requesting an assessment for further support |
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Please highlight the current Mental Health Concerns you have for this patient:
● Details and duration of Mental Health Symptoms ● What interventions (biological, psychological and social) they have had and response to them ● Please attach any relevant clinical letters e.g. Neurology, Hospital discharge summaries / recent brain scans ● Please highlight if they have previously been under the c/o Adults / Older Adults Mental Health Team ● Please highlight if they have previously been given a diagnosis of any Mental Illness ● If referring to Memory assessment services, please provide details of memory screening test that has been carried out (e.g. MMSE, GPCOG) ● If referring to Early Intervention Psychosis (EIP) services, please provide details, nature and duration of any psychotic episodes experienced (Specifying if any have been accompanied by significant risk, distress or decline in functioning)
Please see risk assessment section below for further information around current/historical risk presentation.
Current presentation:
Current measures (including ADSM where completed) Detailed information about current presenting problems, impact on day
to day functioning Relevant Historical
information |
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What actions have been taken to manage the symptoms/difficulties that led to this referral, including referral to other services? Example-IAPT/NHS Talking Therapies, Primary Mental Health Care Team, Social Services, Medication.
Current interventions
Any other services involvement
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Please provide details of any current medication and relevant past medical history: Please include patient’s alcohol and smoking history here (a patient summary of GP notes is acceptable).
Current medications and adherence
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Please provide details of blood tests or other investigations that have been carried out: (a patient summary of GP notes is acceptable)
<Complete
if known> For Older Adult Memory referrals: Please note that in line with NICE guidance and agreed local protocols, we ask that routine bloods including (FBC, U&E, LFT, Thyroid, calcium, B12, folate, glucose, cholesterol, ESR or CRP) are performed before or at the point of referral – ideally within the last six months or more recently if symptoms are more acute.
Has the patient previously had an MRI or CT brain scan? Yes ☐ No ☐
Is the patient willing to have an MRI or CT head scan if it is indicated? Yes ☐ No ☐
Are there contraindications to an MRI scan (pacemaker, shunts, metal implants, claustrophobia)? Yes ☐ No ☐
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Have you identified any significant risks?
Self-harm/ suicidal ideation ☒
Risk of harm to others ☐
Hazards at home ☐
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Vulnerability/exploitation ☐
Risk of harm from others ☐
Wandering/ getting lost ☐
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Falls ☐ Neglect ☐
Driving ☐ Lives alone ☐
Other ☐ (please comment) |
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Please include full risk assessment here – including, but not limited to:
PHQ9 Q9 score Protective factors |
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Please provide details if patient been referred to Social Prescriber
/ Care Co-ordinator or Dementia coordinator?
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Are any other agencies involved in the patient’s care including Safeguarding Team?
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