(Tel: 0113 230 2631 Fax: 0113 278 4710
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Referral Form – LYPFT CMHT’S
This form should be completed fully and as clearly as possible or it may be returned
All of the information provided will be kept PRIVATE and CONFIDENTIAL
PLEASE CHECK AVAILABILITY PRIOR TO SUBMISSION AS WE DO NOT OPERATE A WAITING LIST FOR ANY OF OUR SERVICES
Clients receiving Employment Support from another organisation Will Not be accepted
1. Basic Referral Criteria
Have you spoken to the WorkPlace Leeds Employment Support Team prior to making this referral?
Please tick how your client meets the criteria
NHS Leeds
My client meets all the following criteria:
o Unemployed
o Age 18 years+
o Can travel independently
o Is motivated towards work and their end goal is work
My client meets all the following criteria:
o On CPA in Leeds
o Has a Care Co-ordinator
o Referral does not come at the point of discharge
and is being referred from one of the following services:
o Leeds Community Mental Health Team - please circle which team: West/NW South East/NE
o Psychiatrist
o Aspire
o ICS
o Assertive Outreach Team
Leeds Low Secure Forensic Service:
o Ward 2, Women’s Service
o Ward 2, Men’s Service (Assessment and Treatment)
o Ward 3, Men’s Service (Continuing Treatment and Recovery)
o Forensic Outreach Team
2. Applicant’s Details
Mrs / Mr / Ms / Other: / Surname: / Forename(s):
Date of Birth: / NI No: / Gender:
Telephone: Home Mobile
Address:
Email address:
3. Referrer’s Details
Name: / Profession:
Team/Service: / Telephone:
Email address:
4. Legal Status
5. CPA
6. Length of Care
7. Other support
Which other agencies are CURRENTLY involved in the client’s care? / GPs DetailsName:
Practice:
8. Health
Mental Health Details / Physical Health Details9. Risk Issues
10. Specific Support Needs/Issues
11. Communication Needs
Does your client have difficulty with any of the following?: (please tick and provide brief details)Hearing ¨
Memory, concentration, learning and understanding ¨
Speaking or using language ¨
Details:
12. General Relevant Information to Support Referral
13. Criminal Convictions
14. Authority to disclose information
RISK - PLEASE ENSURE YOU HAVE ATTACHED AN UP-TO-DATE COPY OF THE CLIENT’S RISK ASSESSMENT AND DETAILS/A MAP OF EXCLUSION ZONES IF APPLICABLE.
FOR OFFICE USE ONLYDATE RECEIVED: / DATE CONTACTED:
DATE OF FIRST APT: / ATTENDED Yes ¨ No ¨
REFERRAL ACCEPTED Yes ¨ No ¨ / DATE KEYED ON RECORDBASE:
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Diversity Information
We use the following information to monitor how far our client group represents the diverse communities in Leeds, and to help us work towards fair access to our services for all groups.
How would you describe your ethnic origin? Please tick one box:
¨ / White British / ¨ / Bangladeshi¨ / Irish / ¨ / Asian Other – please state:
¨ / White Other – please state:
¨ / Black Caribbean
¨ / Mixed White & Black Caribbean / ¨ / Black African
¨ / Mixed White & Black African / ¨ / Black Other – please state:
¨ / Mixed White & Asian
¨ / Mixed Other – please state: / ¨ / Chinese
¨ / Gypsy / Traveller
¨ / Indian / ¨ / Other – please state:
¨ / Pakistani
¨ / Kashmiri / ¨ / Do not want to say
How would you describe your Gender? Please tick one box:
¨ / Female / ¨ / Do not want to say¨ / Male / ¨ / Other – please state:
¨ / Transgender
How would you describe your sexual orientation? Please tick one box:
¨ / Heterosexual / ¨ / Bisexual¨ / Lesbian / ¨ / Do not want to say
¨ / Gay / ¨ / Other – please state:
Do you define yourself as disabled? Please tick one box:
¨ / Yes / ¨ / No¨ / Do not want to say
How would you describe your religion? Please tick one box:
¨ / None / ¨ / Muslim¨ / Christian / ¨ / Sikh
¨ / Buddhist / ¨ / Jewish
¨ / Hindu / ¨ / Other – please state:
¨ / Do not want to say
How would you describe your relationship status? Please tick one box:
¨ / Married / ¨ / Single¨ / Co-habiting / ¨ / Do not want to say
¨ / Civil partnership / ¨ / Other – please state:
How would you describe your residency status? Please tick one box:
¨ / British citizen / ¨ / Asylum seeker¨ / EU National / ¨ / Foreign student
¨ / Refugee / ¨ / Destitute
¨ / Do not want to say / ¨ / Other – please state:
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