Download community mental health team for adults referral form

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:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________