LTC Professional Referral form

Patient Details:

Name:

Address:

Postcode:

Telephone Number:

Mobile:

Can we leave voicemail messages?
YesNo

Can we send text messages?
YesNo

Can we contact you by email?
YesNo

Email:

NHS Number:

Date of Birth:

GP Practice:

Ethnicity:

Referrer's Details:

Name:

Referring service:

Telephone number:

Mobile:

Email:

Referrer Designation:

Is the client aware of the referral?
YesNo

Is the patient (or partner) pregnant or have caring responsibility for a child under 24 months?
YesNo

Next of Kin/Emergency Contact Details:

Name:

Relationship:

Address:

Telephone number:

Referral Information

Long term physical condition:

For each condition,please tick and give the date of diagnosis:

COPD / Respiratory Disorder

Diabetes

MSK Problems

Chronic Pain

Cardiovascular Disease

IBS

ME

Fibromyalgia

Mental Health Problem:

Anxiety

Panic Attacks

Depression

Excessive worrying

Unhelpful or distressing thoughts

Other - please give details:

Does the patient have any support around their mental health problem? (Already involved with mental health services)? Please give details:

What is the impact of the patient's mental health problem on their physical health?

Does the patient have any physical health needs that may impact on them attending sessions?

Are there any risks to be aware of? (Suicidal thoughts/self-harm/neglect/substance misuse)