LTC Professional Referral form

Please only complete this form if you are a long-term condition health professional making a referral to the Blackpool Healthier Minds team for a patient with a diagnosed long term physical health condition. Alternatively, you can download and complete this form. (Please note, this form may not meet accessibility standards)

If you are a professional but do not meet the above criteria to complete our LTC professional referral form, then please support your client to self-refer online [Self-referral form] or by phone on 01253 955700

Patient Details:
Name: [patient-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

Date of diagnosis:

Diabetes

Date of diagnosis:

MSK Problems

Date of diagnosis:

Chronic Pain

Date of diagnosis:

Cardiovascular Disease

Date of diagnosis:

IBS

Date of diagnosis:

Fibromyalgia

Date of diagnosis:

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)

Where did you hear about the service?*:

If selected 'other', please state where*:

Please confirm your details below if you give consent for your details to be shared.

I give my consent for the information contained in this referral to be shared with the Blackpool Healthier Minds team.

Name:

Please leave this field empty.