Download Psychological Services - South West Yorkshire Partnership NHS

SINGLE POINT OF ACCESS REFERRAL FORM (KIRKLEES)
PLEASE PRINT
Date of referral……………………………………………………………………..
CLIENT DETAILS
First Name: …………………………………………………. Last Name: …………………………………......................
Address:…………………………………………………………………………………………………………………………
……….……………………………………………………………………………………………………………………………
Postcode: …………………………………………………….
Male / Female
Date of Birth:………………………………………………….
Marital Status………………………………………
Tele No: ……………………………………………… Mobile:……………………………………………………………….
(Please indicate which number they are happy to be contacted on)
Is the patient able to telephone to make an appointment?
Yes/No
NHS No: . ……………………………………
Rio Number: …………………………………… (if known)
Carer name:…………………………………
Carer Contact Number:……………………………………………
Does the patient have hearing/visual impairment
Interpreter/Signer required? Yes/No
Yes/No
Preferred First language…………………………………….
Has the Service User Given Consent to This Referral Yes/No
Ethnicity:………………………………
Is the service user pregnant or has given birth in the last 12 months
Yes/No
Do you believe this to be a memory problem, if so please provide the results below?:MMSE/AMT: Yes/No (please delete)
MSU: Yes/No (please delete)
Bloods:
ECG: Yes/No (please delete)
Yes/No (please delete)
GP DETAILS (PLEASE PRINT)
REFERRER DETAILS IF DIFFERENT TO GP
Name: …………………………………………………………
Name: ………………………………………………
Surgery Address: ……………..…………………………….
Address: …………………………………………..
…………………………………………………………………..
………………………………………………………..
Postcode: ……………………………………………………..
Postcode: ………………………………………….
Tel No: …………………………………………………………
Tel No: …………………………………………….
SOCIAL & PERSONAL CIRCUMSTANCES: (please include details of: social issues, employment, housing,
significant others, family issues, age of children, type of benefits)
Chair: Joyce Catterick OBE
Chief executive: Steven Michael
1.REASON FOR REFERRAL (Nature of the problem e.g. mood, behaviour, hallucinations, delusions etc
including views of significant others)
N.B. If there is evidence of an eating disorder please complete the Eating Disorder Form
2.CURRENT MENTAL HEALTH PRESENTATION (Please give details of the onset and development,
duration and severity of the problem including details on sleep, appetite, concentration, hallucinations,
delusions, mood, behaviour etc)
PHQ 9 Score ………………… GAD 7 Score……………….. (please include a copy of the questionnaire
3. PREVIOUS MENTAL HEALTH HISTORY WITH DATES AND INTERVENTIOINS (Please include details of
both psychiatric and psychological interventions, if known)
4.RELEVANT MEDICAL HISTORY
5.CURRENT MEDICATION – including details of when prescribed
Chair: Joyce Catterick OBE
Chief executive: Steven Michael
6. REFERRERS OPINION (Please provide an opinion regarding the appropriate outcome of this
referral, if known), please tick:
CMHT Adult
IAPT
Psychology
Insight Team
ADHD Adult
Intensive Home Based Treatment
CMHT Older People
Care Home Liaison
Memory
Outreach Team
Crowlees
7. RISK ASSESSMENT: Please provide as much information as possible.
Is the Client
Historical Current Details
Evidence of violence and
aggression in what context
and who is at risk?
Yes / No
Yes / No
Inappropriate sexual
behaviour, in what context
and who is at risk?
Yes / No
Yes / No
Substance Misuse?
Drug/Alcohol?
Yes / No
Yes / No
Safeguarding
Children/Adults issues?
Yes / No
Yes / No
Expressing suicidal
ideation? Nature,
frequency, when last
experienced, likelihood of
acting on thoughts,
plans/action, preventative
measures?
Yes / No
Yes / No
Evidence of Self-Harm:
Nature and Frequency?
Yes/No
Yes/No
Evidence of psychosis?
Yes/No
Yes/No
Forensic History
Yes/No
Yes/No
Frequency and amount?
Symptoms?
Name: ……………………………………………………………...
Profession: …………………………………………
Signature of Referrer: …………………………………………..
Date: …………………………………………………
Please include any additional information on a separate sheet
Please return this referral form either via post to:
Kirklees Single Point of Access Team, Beckside Court, 286 Bradford Road, Batley, WF17 5PW or
phone 01924 284555 or Fax to 01924 284567
Chair: Joyce Catterick OBE
Chief executive: Steven Michael