EXAMPLE Newcastle Community Treatment Team referral form

EXAMPLE Newcastle Community Treatment Team referral form

Please see below an example of a completed Community treatment team referral form for Newcastle talking therapies. 

Please see referral guide when deciding if the referral needs to go to the CTT or Newcastle specialist community pscyhology service.

Newcastle Talking Therapies Community Treatment Team
Referral Form 


Consent given from Patient for Referral 

YES

 X

NO

 

 

Demographic Information:

Title:

 Mr

First Name: 

Test

Last Name:

Client

Date of Birth:

00/00/00

Address: 

Full current address

Postcode: 

Current postcode

Home Telephone Number 

Check details and complete

Can we leave messages on home number? 

Y/N

Work Telephone Number: 

Check details and complete

Can we leave messages on work number?

Y/N

Mobile Telephone Number:

Check details and complete

Can we leave messages on mobile number?

Y/N

Email Address:

Check details and complete

NHS Number: (on MPB Referral tab)

 Check details and complete

Gender: 

 Check details and complete

Can Communicate in Spoken English:

 Check details and complete

Can understand written English:

 Check details and complete

Language of Interpreter if needed:

 Check details and complete

Main Spoken Language: 

 Check details and complete

Vita Health Group Reference ID (MPB Number):

 Check details and complete

 

GP Details – Please check the clients current GP surgery details

GP Surgery:

 

GP Name and Address:

 

GP Contact Number:

 

 

Referral Details

Referral Date:

 Date referral sent to network team

Name of Referrer:

 Your name

Type of Referral: 

Iapt Assessed, Referred by Network clinician                                     

Risk Assessments:

Please document PHQ9 Q9 details

Care Cluster (If known):

 

PHQ Score:

Most recent PHQ9 score

GAD Score:

Most recent GAD7 score

WSAS:

Most recent WASAS score

 

Network therapists – please leave this section blank

 

Only to be completed in Weekly Discussion Meeting 

Date of Discussion:

Summary of Discussion:

Outcome:

Referral Accepted by S4:

Yes

 

No

 

Referral; Accepted by Vita:

Yes

 

No

 

 

History of Difficulties:

Please include a detailed outline of the client’s mental health difficulties and any relevant contextual/background information.

Current Presentation:

Detailed information about current presenting problems, impact on day to day functioning

Any screening information that has been collected

Please include a full and up to date risk assessment, including any risk history and safety plan

Clients Goals and Client Perspective on Difficulties:

Detail the client’s goals for therapy, and their understanding of their difficulties.

Please outline what therapy the client has already engaged with, including any therapeutic history or previous mental health diagnosis.

Please document if the client is taking any medications

Rationale for Community treatment team:

Please document why this client is not considered suitable for short term talking therapies

Please document why the referral is going to the community treatment team (rather than the Specialist Community Psychology Service – see referral guide on Zoho helpdesk)

 


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