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Transcript
COMMUNITY MENTAL HEALTH TEAM FOR ADULTS REFERRAL FORM To: Community Mental Health Team Tel: Fax: …………………………….. 1. Name of Client/Patient:____________________ Address:________________________________ ________________________________________ Post Code:_______________________________ Tel No:__________________________________ Dob:__________________________ Marital Status:_________________ Male/Female:__________________ 2. General Practitioner: Name:_________________________________________________ Address:_______________________________________________ _______________________________________________________ Tel:___________________________________________________ 3. Referring Agent: Name:_________________________________________________ Address:_______________________________________________ _______________________________________________________ Tel:___________________________________________________ 4. Other Agencies/Services involved with client:________________________________________ _______________________________________________________________________________ 5. Current Medication:_____________________________________________________________ 6. Is the client aware that a referral is being made? Has the client agreed to the referral? If the referrer is not the GP is the GP aware of the referral? 7. Reason for Referral:_____________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ YES/NO YES/NO YES/NO 8. Client’s current state (Include as necessary: symptoms, behaviour, emotional state, ability to cope with day to day life, family, marital and personal relationships, drug/alcohol etc): _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 9. Relevant history and previous treatment: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 10. Risk: In you opinion how serious are the following risks? High Risk Moderate Risk Low Risk Harm to self Harm to others Self neglect Psychiatric hospital admission 11. Any other information: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
