EXAMPLE Newcastle Specialist community psychology service referral form

EXAMPLE Newcastle Specialist community psychology service referral form

Please see below an example of a completed Newcastle specialist community pscyhology service referral form for Newcastle talking therapies. 

Please see referral guide when deciding if the referral needs to go to the NSCPS or community treatment team.

Newcastle Specialist Community Psychology Service Referral Form

 

For discussion in Interface meeting   

DEMOGRAPHIC INFORMATION

Title:

Mr

First Name:

Test

Last Name:

Client

Gender: 

Check details and complete

Date of Birth:

00/00/00

NHS NUMBER:

Check details and complete (on MPB Referral tab)

Address:

 

Check details and complete

Can communicate in spoken English

Yes    No  

Post Code

Check details and complete

Understands written English

Yes  No

Home Tel:

Check details and complete

 

Work Tel:

Check details and complete

Language of interpreter if needed:

Check details and complete

Mobile:

Check details and complete

Main spoken language English:

Yes  No

GP DETAILS

GP Name:

Check details and complete

Telephone:

Check details and complete

Surgery:

Check details and complete

Fax:

 

REFERRAL DETAILS

Name of Referrer: Therapist name and contact email                         

Referral Date

Date referral sent to network team

Type of referral

IAPT assessed    

 

Care Cluster (if known)

 

PHQ Score

/27

GAD score

/21

other

Disorder specific measures

Consent given by patient for referral?  Yes  No

 

 

Risk Assessment information (risk to self and others)

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

Current presentation (current difficulties & symptoms, don’t assume PTSD/CPTSD just because there is past trauma/ACES)

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

Any screening information that has been collected

 

History of difficulties

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

Previous therapies & interventions (consider previous clinical outcomes, what worked, why didn’t therapy work, why might therapy help now, readiness for change focused therapy)

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

Client goals and client perspective on difficulties – what does client want to focus on specifically and why?

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

 

Rationale for making referral to NSCPS

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

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

 


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