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REFERRAL
Referrer to Complete
Referrer to Complete - step 2
Date:
Time:
Referrer Name:
Referrer Position:
Referrer Trust:
Responsible Trust for patinet's care
Name of Service user and preferred pro-noun (He/Him, She/Her, They/Them):
Patient NHS Number:
Date of Birth:
Name and Contact Details of Next to Kin
Nearest Relative
Legal Status (informal/Detained)
MHRT Date
Care Co-ordinator / Case Manager
Contact Details
Current GP contact information
Diagnosis
Reason for Referral / brief summary of current presentation
Past Psychiatric History i.e. previous admission and previous treatments
Any physical Health Issues (Historical & Current) including adverse reactions to medication / allergies / underlaying physical health conditions
If there are mobility issues - outline what mobility assistance are required
Pregnancy
Is the patient pregnant?
YES
NO
How far on is the pregnancy?
Is this a wanted pregnancy?
Are the presenting mental health issues related to the pregnancy?
Is the patient engaged with her maternity and perinatal services?
Is there a crisis plan in place for a pre-term birth, an emergency with the pregnancy/ birth?
What services are involved? Contact names of local midwife, family etc.
What is the discharge plans, is the patient homeless, living with a partner/family/carers?
Will the baby be staying with the mother, be placed for adoption etc
Are social care involved and if yes names of professionals involved.
Highlight – high risk medication
Any health conditions that may complicate the pregnancy?
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Current Medication / Including of PRN
Current Observation Level
Current location / placement. EG - acute hospital, s136 suite, PICU, Police custody, Prison, Usual place of residence
Risks
Please complete the table of risk or attach most recent risk assessment
CURRENT RISK:
HISTORICAL RISK:
Suicide
YES
NO
YES
NO
Deliberate self-harm
YES
NO
YES
NO
Self-neglect
YES
NO
YES
NO
Non-adherence with treatment
YES
NO
YES
NO
Violent, aggressive, intimidating behaviour
YES
NO
Date of most recent incident
Absconsion / Escape
YES
NO
YES
NO
Inappropriate sexual behaviour
YES
NO
YES
NO
Using or supplying drugs or alcohol
YES
NO
YES
NO
Arson
YES
NO
Date of most recent incident
Accidental fire setting
YES
NO
Date of most recent incident
Risk to staff
YES
NO
YES
NO
Risk to harmful substance withdrawal
YES
NO
YES
NO
Physical health
YES
NO
YES
NO
Internet and social media
YES
NO
YES
NO
Other risk factors (please detail)
YES
NO
YES
NO
If you have answered yes to any of the above risk please summarise here:
List of recent incidents - last three months
Any safeguarding concerns (Please state the body they have been raised with)
Any other relevant information:
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