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HIV Psychology and Psychiatry Mental Health Service referral Form

Please do not hesitate to contact us on 0300 304 0077 if you are uncertain about this referral, our service descriptions and referral criteria. Please send completed form to SPNT.HIVMHREF@nhs.net

Inclusion Criteria

We will accept referrals as long as the following criteria are met:

A confirmed HIV diagnosis.
Resident of Brighton and Hove.
Over 18 years old.
Psychological and/or psychiatric problems associated with HIV status, such that their psychological problems are impacting on their ability to cope with HIV, or that the biological, psychological or social aspects of HIV infection are impacting on their psychological well-being.
Patient presentation deemed too complex for primary care psychological therapies services.
This service is not for patients who require urgent and acute psychiatric care. These patients should follow the usual urgent care pathways via rapid response and emergency mental health service pathways

HIV Psychology and Psychiatry Mental Health Service referral Form

Referrer Information

Date of Referral:

Referrer Name:*

Referrer Contact Email:*

Referrer Contact Phone:

Please confirm your email address:

Patient Information

Patient Name:*

Date of Birth:*

Address:*

Phone Number:*

NHS Number:*

Clinic Number:

GP Name:*

GP Address:

GP Postcode:

Consent given to contact GP:*

Yes

Unsure

Reason for Referral

Reason for Referral:*

A) Clinical Psychology

B) Psychiatry

Is the patient currently seeing any other counselors, therapists, psychiatrists or psychologists?:

If Yes, have you consulted with them about referring on to us? Please do so before sending a new referral. Please give details of discussion:

Which, if any, mental health professionals has the patient seen before?:

Is the patient currently on any medication for mental health?:

Yes

Unsure

If Yes please give details:*

Please list all other prescribed medications:

Screening Measures: PHQ-4:

Screening Measures: GAD-7:

Screening Measures: PHQ-9:

Do you have any concerns about self-harm or harm to others?:

Description of problems, ensuring this is associated with HIV:

Background information (social situation, relationships, physical health, substance use):

History of problems (previous difficulties and relevant prior life events):

Any other information:

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