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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