Cnwl centre for Compulsive and Addictive Behaviour Referral Form

tarix	24.06.2016
ölçüsü	127.5 Kb.

CNWL Centre for Compulsive and Addictive Behaviour - Referral Form

1. Client Details

Date of referral:

Is this a self referral?

Yes

Have you referred here before?

Yes

Title:

First name:

Surname:

Also known as:

Age:

Date of Birth:

Address:

Postcode:

Home phone:

Mobile:

E-mail:

NHS Number:

Where did you hear about the Service?

Local Authority / Borough of Residence:

*If self referral please ignore section below and move to section 3. 3

2. Referrer’s Details
Referral Agency:		Referrer’s Name:
Address:
Postcode:
Telephone:	Fax:				E-mail:
Main reason for referral:
Has the client accessed this type of service before?				Yes:		No:
Where:			Date:
IMPORTANT NOTE: REFERRALS FROM EXTERNAL AGENCIES All referrals from external agencies must be accompanied by a recent report highlighting information that may be relevant to the assessment, particularly around difficulties and risk. Please note that the client will not be offered an assessment until this information is received from the referrer.

Personal Details (circle or mark as appropriate)

Consent: We ask for the following information about you to help us monitor and improve our services. We request your consent to contact your GP and any other agencies involved in your treatment. When you attend your appointment you will be asked to give consent for CNWL to contact other agencies. See confidentiality form at your first appointment for more information about this. However, please contact us to discuss this further before your first appointment if you have concerns.

Gender

01 - Male 02 - Female

03 - Other

Marital Status

01 - Single 03 - Cohabiting 05 - Separated

02 – Married 04 – Divorced 06 - Widowed

Sexual Orientation

01 – Bi-sexual 02 – Gay 03 – Heterosexual 04 – Lesbian 05 – Not Known 06 – Other

07 – Prefer not to say

Children

Any children under 16? 01 - Yes 02 - No 03 - Would rather not say
If so, how many children live with you / the client at least part of the time?
Are you / is the client pregnant? 01 - Yes (state due date) 02 - No 03 - Not Applicable

GP Details

Are you/ Is the client registered with a GP? Yes No

GP Name:

Address:

Postcode:

Telephone:

Ethnicity
(Circle or mark one option only as appropriate)

White

01 – British

02 - Irish

03 - Any Other White Background

– please state:

Mixed

04 - White & Black Caribbean

05 - White & Black African

06 - White & Asian

07 - Any Other Mixed Background

– please state:

Asian or Asian British

08 - Indian

09 - Pakistani

10 - Bangladeshi

11 - Any Other Asian Background

– please state:

Black or Black British

12 – Caribbean

13 - African

14 - Any Other Black

Background

– please state:

Other Ethnic Groups

15 - Chinese

16 - Any Other Ethnic Group –

please state:

Religion/Belief

Nationality/

Country of Origin

Main Language Spoken

Interpreter Needed?

Yes

If yes state language:

Special Needs

Please tell us whether you / the client has disabilities or special needs

Main Occupational Status
(Circle or mark one option only as appropriate)

01 - Employed (full-time) 07 - Main family carer (child/adult)

02 - Employed (part-time) 08 - Retired

03 - Self-employed/own business 09 - Other – e.g. Doing unpaid / voluntary work

04 - Unemployed (looking for work) 10 - Other – e.g. Permanently unable to work

05 - Student (full-time) due to long- term sickness or disability

06 - Student (part-time) 11 - Other – e.g. On a Government training scheme

12 - Other – please state:

Accommodation Type
(In which of these ways do you occupy this accommodation?)

01 - Buying it with the help of a mortgage or loan

02 - Own it outright

03 - Pay part rent and part mortgage (shared ownership)

04 - Rent it

05 - Tied accommodation (e.g. where the accommodation goes with your job)

06 - Live here rent-free (including rent-free in relative’s/friend’s property)

07 - Homeless

4. Identification of reasons for referring
Details of issue(s)

Over the last 2 weeks how often have you been bothered by the following symptoms?
			Not at all 0	Several days 1	More than half the days 2	Nearly every day 3
1. Little interest or pleasure in doing things.
2. Feeling nervous, anxious or on edge.
3. Feeling down, depressed or hopeless.
4. Not being able to stop or control worrying.
Identification of related issues, specific risk and priority need. Please indicate if you have / the client has issues in relation to any of the following (circle or mark as appropriate)
Mental Health * Physical Illness* Young Person (Under 18) Pregnant woman Child/ren may be in need Drug Use Homless Oustanding legal**	Current self harm Risk of causing physical harm to others Physical disability Alcohol Problems Probation Social Services Other – please describe	Comments: * Current ill-health requiring medication or intervention ** Please give details, i.e. court date/warrant notice

5. Client Consent (Please tick or mark all that apply)				YES	NO
I consent to this referral being made
I consent to details of the referral outcome being sent to the referrer
I consent to details of the referral outcome being sent to my GP
By what method would you prefer to be contacted by a member of CCAB Clinic staff? (Please tick or mark all that apply)
I consent to being contacted by telephone (landline)
I consent to being contacted by telephone (mobile phone)
One or both of the following methods of communication must be ticked to enable us to send written communication
I consent to being contacted by e-mail OR
I consent to being contacted by letter
Signed (Client)	Date:	Signed (Referrer)	Date:

When completed, please send this form (either by e-mail, fax or post) to the CCAB:
Crowther Market, 282 North End Road, London SW6 1NH
Fax: 020 7381 7723 E-mail: ccab.cnwl@nhs.net Phone: 020 7381 7722
Website: www.cnwl.nhs.uk/ccab.html