Northern CLDT

1. Client Details

Full Name: *

Date of Birth: Day

Date of Birth: Month

Date of Birth: Year

Address (or last known address if currently in hopsital): *

Current Address (if different from above - i.e in hospital):

CIS Number:

NHS Number: *

Telephone: *

First Language: *

Lives With:

Marital Status: *

Divorced

Separated

Single

Widowed

Married / Civil Partnership

Accomodation Status: *

Independent Living

Residential

Supported Accomodation

Other

Please Specify:

Local Authority: *

Mental Health Status: *

CTO

Section

Informal

N/A

Is the client an ex-member of British Armed Forces or dependent on such a person?*

Yes

No

Unknown

Is the client employed? (Paid or Voluntary)*

Yes

No

Unknown

2. GP Details

GP Name: *

GP Address:

GP Telephone: *

GP Email: *

3. Next of Kin

Next of Kin Name: *

Next of Kin Address:

Next of Kin Telephone: *

Next of Kin Email: *

Relationship to person named in section 1: *

4. Primary Contact

Primary Contact Name: *

Primary Contact Address:

Primary Contact Telephone: *

Primary Contact Email: *

Preferred contact method: *

Email

Text

Call

Letter

Other

Please Specify:

Is it appropriate to contact the client directly?*

Yes

No

Please Explain:

Relationship to person named in section 1: *

5. Consent

To comply with the Mental Capacity Act, it is really important that we are informed if the person is aware of the referral. We may telephone or write to the client and it may cause upset if they are not aware of their information being discussed with others. If you have not sought consent it is helpful for us to know why that decision was made and to know if the person is aware of the support they may need. If you are not sure how to do this please ring for advice

Does the client know what the referral is about? *

Yes

No

Does the client have the capacity to consent to information sharing? *

Yes

No

Does the client consent to information sharing with their GP? *

Yes

No

Does the client consent to information sharing with their next of kin? *

Yes

No

If consent has not been sought please explain why not:

6. Details of person completing this form

Please make sure you complete this section and that you have included all the relevant information including telephone numbers and email as we may need to go back and obtain more information. The job title only needs to be completed if you are a paid professional in relation to the client.

Date form completed:

Completer Name: *

Completer Job Title: *

Completer Address:

Completer Telephone No: *

Completer Mobile:

Completer Email: *

Completer Relationship to client: *

Has the client agreed to the referral?*

Are there other agencies involved with this client?*

Yes

No

Please confirm your email address:

7. Social Worker Details

Social Worker Name: *

Social Worker Job Title:

Social Worker Address:

Social Worker Telephone No:

Social Worker Email:

8. Supporting Information

Reason for referral:*

What are the current concerns regarding risk factors?*

What do you hope to gain from this referral?

Are there any particular areas you would like us to focus on?

Has the client had an annual health check?*

Yes

No

Please Specify Date and Outcome:

List of medications:

Terms & Conditions

On receipt of the referral we will consider whether or not a learning disability service may be the most appropriate service. If an appointment is offered this will be prioritised based on the presenting need.

The information you have provided will only be used for the purpose of receiving your referral and contacting you for further information about your referral if required. Your information will not be shared with anyone else without your consent. Information will be held as a part of the service user's record in line with the NHS Records Management Code of Practice.

I have read and agree with the above terms and condtions.*

I believe the information above is correct and true*

I have read the eligibility criteria.*

Northern CLDT

Northern CLDT

Contact

Address

1. Client Details

2. GP Details

3. Next of Kin

4. Primary Contact

5. Consent

6. Details of person completing this form

7. Social Worker Details

8. Supporting Information

9. Important Information

Terms & Conditions