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Referral Form Max Glatt Unit on Mulberry North Ward South Kensington & Chelsea Mental Health Centre 1 Nightingale Place, London, SW10 9NG Tel No. 02033153153 Fax No. 02033156079 1|Page Max Glatt Unit May 2014 SECTION 1- DEMOGRAPHICS Client Details NHS No. Name DoB. Address Jade No. Male Permanent Temporary Hostel NFA Registered homeless Sex Postcode: Tel No Yes Yes Yes Yes Yes Female No No No No No email Ethnicity White: British Mixed: White & Black Caribbean Asian/Asian British: Indian Asian: Other Other: Arab Language White: Irish Mixed: White & Black African Asian/Asian British: Pakistani Black/Black British: African Other (Please state): White: Gipsy or Irish Traveller Mixed: White & Asian Asian/Asian British: Bangladeshi Black/Black British: Caribbean Interpreter Yes White: Other Mixed: Other Asian/Asian British: Chinese Black/Black British: Other Black No Religion Buddhism Christianity Hinduism Islam Judaism Other (Please state): Sikhism Jainism No Religion Homosexual Bisexual Single Married Divorced Civil Union Cohabitating Sexuality Heterosexual Other (Please State): Marital Status Separated Other (Please state): Child Care Does the client have children under the age of 18 Number of children under 18 Are any of the children living with client? Are any of the children looked after or in foster care? Are any of the children on child protection register? Does the referrer have any current child protection concerns? If “Yes” please provide details below including any actions taken. Yes All Yes No Some None No Yes No Yes No 2|Page Max Glatt Unit May 2014 Details: (If social services involved please provided details of social worker in section 2) SECTION 2- PROFESSIONAL CONTACTS Referrer’s Details Referring Agency Referrer’s Name Address Contracting Borough Postcode: Tel No. Email Care Manager Address Fax No. Postcode: Tel No. Fax No. GP Details GP Name Address Postcode: Tel No. Email Fax No. Pharmacy Details (for Clients on Opiate and other Substitute Prescription) Address Postcode: Tel No. Fax No. Legal Probation officer Address Postcode: Tel No. Fax No. 3|Page Max Glatt Unit May 2014 Social Services Social Worker Address Postcode: Tel No. email Fax No. SECTION 3- Substance Use– please attach any recent relevant reports Requested duration of admission 7 days 10 days 14 days Other: Reason for Admission Alcohol Detoxification Opiate Detoxification Opiate Stabilization Opiate Reduction Benzo Detoxification Benzo Stabilization of Benzo Reduction Stimulant Detoxification Other (Please State): methadone Buprenorphine Lofexidine of of from mg to mg of from mg to mg Additional objectives to achieve from admission Substances including Alcohol & Tobacco Amount (units, grams, tablets) No. of days used in last 28 days Source (SMS, GP, street) Route (IV, oral, smoke) 4|Page Max Glatt Unit May 2014 Any history of IV drug use Details: Yes Any previous treatment for substance misuse? Yes Details: (previous detoxifications and outcomes/any psychosocial interventions) No No SECTION 4- PSYCHIATRIC HISTORY– please attach any recent relevant reports Does the client have any mental health diagnosis? Please provide specific diagnosis F00-09 Organic, including symptomatic mental disorder F20-29 Schizophrenia, schizotypal and delusional disorder F30-39 Mood (affective) disorder F40-48 Neurotic or stress related or somatoform disorder F50-59 Behavioural disorder associated with psychological disturbance & physical factors F60-69 Disorder of adult personality and behaviour Learning Disability Please provide details of any mental health concerns Details: (Any recent contact with CMHT, HTT or CRT/ Previous psychiatric admissions, MHA assessment and treatment history) Does the client have any history of self-harm or suicidal attempts? Details: 5|Page Max Glatt Unit May 2014 Current mental status Details: (Please also include any behavioural difficulties or concerns in this section) Is the client known to mental health services? Details: (care coordinator, address and contact details) SECTION 5- MEDICAL HISTORY– please attach any recent relevant reports Current physical health status or any recent medical treatment required Details: Any recent A&E attendance? Yes No Does the client have any medical conditions? Details: Is the client under any specialist team? Details: 6|Page Max Glatt Unit May 2014 Are there any mobility issues or disability? Details: BBV status Date of Last BBV screen Hepatitis B status Hepatitis C status HIV status Hepatitis B vaccination completed Any comments Yes Yes Yes Yes No No No No Allergy Status DIETARY REQUIREMENTS Halal Kosher Vegetarian Other: SECTION 6- CURRENT MEDICATIONS COMPLIANT PRESCRIBED MEDICATION PRESCRIBED BY DOSAGE YES NO Please advise the patient to bring in all their prescribed medication for duration of admission 7|Page Max Glatt Unit May 2014 SECTION 7- OTHER DETAILS Personal History Details: (Early childhood, schooling, traumas, occupational history & relationship history) Family History Details: Is there anyone (partner, relative or carer) who would like to see family therapist during client’s admission? Would the client like to be seen together with the family member Yes No Yes No Current Social/Housing Issues Details: If the client is not able to return to his address please provide details of alternative arrangements made on discharge Forensic Does the client have any history of aggression or violence? Does the client have any Criminal convictions? Does the client have any outstanding legal issues? MAPPA Involvement Details: Yes Yes Yes Yes No No No No Safeguarding Issues Details: 8|Page Max Glatt Unit May 2014 SECTION 8- AFTERCARE Aftercare Package For smooth and safe discharge of clients from the unit after completing detoxification it is crucial that the treating team is aware of the aftercare arrangements. This should include follow up arrangements for physical health and mental health needs. Any social care package required should also be included. Aftercare arrangements should be available at the time of referral. If due to some reasons aftercare cannot be finalized before admission it would be the responsibility of the referring team to inform the in-patient team of aftercare plans within 5 days of admission. If the client is to attend keyworker sessions, groups or day programme on discharge from the unit please provide details of groups, start dates, number of days per week that the client will be attending. If the client is to attend residential rehabilitation please provide details and transport arrangements. If the keyworker or care manager are away during the period their client is at MGU please provide details of person that can be contacted in case of need. Substance misuse: Physical health: Mental Health: Social Care: Other: Contingency plan in case of premature discharge: 9|Page Max Glatt Unit May 2014 Documents Check List (No need to fill part of the form if supporting document has relevant information) Completed Referral Form Current Risk Assessment Funding Agreement if appropriate Programme Agreement Visitor’s List GP Summary Recent Psychiatric Reports (If under mental health team) Recent Medical Reports Recent Blood Results (client 60 or above, history of liver disease, renal disease or severe eating disorder must have recent blood test) ECG (client over 60 or history of cardiac condition must have an ECG) Please complete the form in full. Incomplete form will be returned to the referrer and may result in delays Please email completed referral form to [email protected] Supporting documents can be faxed to 02033156079 For Urgent admissions please contact Bed Manager on Tel No. 02033153153 10 | P a g e Max Glatt Unit May 2014
