Referrer Details

Referrer Name : <Your name>

Referrer Position : <Your Details>

Telephone :<Your telephone number>

Email: <Your email address>

Patient Details                      Please check all details are correct and up to date

Title: <Patient Name>

First Name: <Patient Name>     Known As: <Patient preferred name>

Surname: <Patient Name>

Home Address: <Patient Address>

Home Tel: <Patient Contact Details>

Mobile: <Patient Contact Details>

Current Address if different from above:

„      

Date of Referral: <Today's date>

NHS number: <NHS number>

Gender: <Gender>

Ethnicity: <Ethnicity>

Date of Birth: <Date of Birth>

Age: <Patient Age>

Are they carer?:               Yes

Do they have a carer:      Yes

Consent to Share

Has the patient consented to share out their care record?

 Consented to Share     

Communications / Other Considerations

Language: <Main spoken language>

Interpreter required?      Yes   No

CONTACTING THE PATIENT

Is the patient aware of and consenting to the Referral

 Yes

Does the patient consent to secondary care services contacting them on their mobile or sending a text?

 Yes  No

If no, please specify alternative contact preferred    

„     

Special Needs to Consider (tick all that apply)

  Vision impairment 

  Physical disability          Mobility

  Hearing impairment       

  Learning disability  

  Other – please specify „      

Children Details

Children: Please give details of all children under 18 known to have regular contact with the patient (if possible please include name, DoB, address if different to patient, GP details

„      

Is there a young carer in the family?

„  

Next of Kin Details

GP Details

Name: <Relationships>

Address: <Relationships>

Contact Details: <Relationships>

Relationship to patient: „      

Registered GP: <GP Name>

Practice: <Sender Details>

Address: <Sender Address>

Tel: <Sender Details>

Referral Details: EXAMPLE BELOW

Reason for Referral    .

„ 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

Please see risk assessment section below for further information around current/historical risk presentation.

Current presentation: Include nature, duration and severity of mental health problems and current circumstances e.g. behaviour, mood, psychotic symptoms, and any suggested or requested inputs.

PHQ9:
GAD7:

(include any other questionnaires completed)

Relevant Historical information:

Social and Personal Circumstances    Give details of lifestyle / occupation / social circumstances including any accommodation issues especially any significant current life stresses

„  Please document

Risk Assessment   Based on the information you have available, are there any current or historical risks (tick Yes or No) and give details :

PHQ9 Q9 score:

Please include full risk assessment here – including, but not limited to:

PHQ9 Q9 score
Current and historical thoughts, plans, means, intent around suicide
Current and historical thoughts, plans, means, intent around self-harm

Protective factors
Current triggers, and risk factors
Risk of harm to/from others
Any safeguarding concerns or disclosures

Safety plans, risk management plans, DASH, and any actions taken to safeguard

Suicidality…………………..

Self-harming behaviour......

Risk to others……………..

Current Substance Misuse

Safeguarding concerns 

Evidence of Self-neglect…

 Yes  No

 Yes  No

 Yes  No

 Yes  No

 Yes  No

 Yes  No

Other risks /issues that might impact assessment e.g. gender of assessor or requiring 2 clinicians 

 Yes   No  „     

Significant others concerns „ Please document any concerns here

Legal Information     Insert any legal considerations e.g. Deprivation of Liberty, Mental Capacity, Lasting Power of Attorney, Safeguarding, Advance Decisions

Primary Care to add DoLS Applications and MCA merge fields.  Configured lists currently not set up in MH Unit SystmOne Also include free text box

„ Please document any concerns here

Clinical Details

Marker

Last Value

Marker

Last Value

BP:

(If known and relevant)

Pulse:

(If known and relevant)

Hba1c:

(If known and relevant)

Cholesterol:

(If known and relevant)

Smoking Status:

Smoking status

Frailty:

(If known and relevant)

BMI:

(If known and relevant)

Current drug use, and any drug use history

Alcohol:

Current alcohol consumption and any alcohol related history

Medical History

Past Medical History Insert past history, including dates of any investigations or interventions especially past history of mental health treatment and any information regarding engagement.

Current interventions
Any previous mental health support
Any previous mental health diagnosis

Any other services involvement

 Active Problems Insert any ongoing health issues. Is the patient currently receiving other medical care, investigations or treatment?

 Long term health conditions or disabilities

Current Acute Medication

Current medications and adherence

Current medications and adherence

Allergies and Sensitivities

Please document any concerns here

Memory Service Referrals – Not applicable (please leave blank)

For memory services referrals, the following fields must be completed.  PLEASE ENSURE ALL INVESTIGATIONS HAVE BEEN DONE.  Failure to do so may result in the referral being returned. 

MMSE/AMT:

<Scored Assessment(table)>

„      

6CIT:

<Scored Assessment(table)>

„      

Bloods:

Hb <Numerics>, WCC <Numerics>, Plts <Numerics>, MCV <Numerics>, Neut <Numerics>

„      

U&E

Na <Numerics>, K <Numerics>, Urea <Numerics>, Creat <Numerics>, eGFR <Numerics>

„      

ECG:

„      

Other physical Investigations e.g. MRI, CT:

„