Adult Forensic Referral
Fax: 0191 223 28 81ete
ADULT FORENSIC REFERRAL
WESTBRIDGE
You can only complete electronically and forward as an email attachment to:. An email confirming receipt of referral will be sent within 1 working day, you can contact the team on 0191 2930530 if you have any queries.
WESTBRIDGE COMMUNITY FORENSIC SERVICE
REFERRAL FORM
Date of Referral:
Name: / DOB:Current Address: / Tel:
Rio No: / NHS No:
Mental Health Act Status: / Ethnic Origin:
Name / Address / E-mail Address / Telephone No
Referrer & Designation
Are all of the professionals involved in this persons care, aware of, and in agreement with, the referral to Westbridge?: YES NO
If No, please detail who is not aware / disagrees with the referral, and the reasons for this:
Date of next CCR/CPA:
Which Local Authority has responsibility for 117 Aftercare?
Who is allocated from this Authority?i.e. Social supervisor/ social worker:
Housing History: Please provide a list of previous addresses in the last five years?
MAPPA / MARAC: Known to MAPPA / MARAC:YES NO
Level:
Is the patient entered on Sex Offenders’ Register or subject to a Sexual Offences Prevention Order?
Name / Address / Email Address / Telephone Number
Consultant Psychiatrist:
RC: (if different from above
Care Co-ordinator:
GP:
Other Agencies:
Local Authority Social Worker:
SHARING AND GATHERING INFORMATION ABOUT YOU DURING ASSESSMENT.
NAME: ______
NHS Number: ______
DATE OF BIRTH: ______
As part of our assessment process we gather information from other services and agencies. In combination with what you tell us about yourself this helps us to get a clear picture of your history and current needs as well as any risk of harm to yourself and to others. The information gathering process will only relate to records that are relevant to your assessment and, with information you give us, will be kept in your health record (written and computerised) to help us to provide you with the most appropriate care. We have a duty to keep information about you private and confidential. However, in certain circumstances, there may be occasions where it is necessary to share information without your consent in accordance with trust policy, common law obligations and the data protection act (1998), as appropriate, for example to protect a child or young person or someone else from harm. In these circumstances, the information shared will always be kept to the minimum necessary and will be handled under the terms of the NHS Confidentiality Code of Practice.
Do you consent to us seeking and sharing information as part of your assessment?
YES ⃞ NO ⃞
Are there any exceptions or limitations to this e.g. If there are people you DO NOT want us to contact at this stage please give their names/addresses and relationship to you:
Who else would you like us to share with or gather information from such as family, carer or friends?
Personal History: Including education and employment history:Current Diagnosis:
Reason for referral: Please indicate the following: current and future rehabilitation needs/goals; desired outcome of this assessment: details of risks posed; specific treatment undertaken; how the person would benefit from acceptance at Westbridge.
Brief Mental Health History Please explain / indicate the following –
Previous diagnosis, symptoms of mental distress, past indication of mental illness/personality disorder, treatments/groups offered, current symptoms of distress, current diagnosis, current indication of mental illness/personality disorder, current treatments being offered (OT/social/psychology), MSE, please include up to date reports, level of leaves and length of time accessing them, use of time, finances
Medication:
Please list all current medication taken. Indicate any issues relating to compliance with these. Describe any progress with regards to self-administration.
History of Violence/ Sexual Violence, Risk to Others Please detail a chronology of all previous incidents of concern including index offence, violent behaviours/ideas, severity, location, circumstances, precipitants, child protection issues, victim issues, exclusion orders, restraining orders
Current Risk of Violence/ Sexual Violence to Others Please detail what are the current risks and to whom, any evidence of escalation, pertinent factors- e.g. substance use, relationship difficulties, child protection issues, victim issues, etc. / NB Please attach most recent Risk Assessment
Other Episodes of Criminality: Please detail offences (alleged or actual) that are not violent offences (e.g. acquisitive offences), and any formal sanctions relating to these.
Other Risk factors:
Please detail details of other risk behaviours (e.g. self-harm, self-neglect; homelessness)
Engagement Issues Please detail any difficulties with attendance/motivation and engagement with treatment.
Service Users Understanding of Referral Is the service user aware of the referral, what was discussed with the client, do they have any expectations or fears?
Medical / Physical Needs:Please detail the following:
current medical issues, mobility or physical impairment; hearing or sight difficulties; cultural considerations; literacy or language difficulties)
Cultural and Spiritual Needs:
Please indicate any specific cultural or spiritual needs, such as ; cultural considerations; literacy or language difficulties.
Accessibility / Risk issues pertinent to the assessment:
Does the person have any accessibility needs / risk issues that need consideration prior to the assessment?
Please check the following is included before returning this form:
Most recent Risk AssessmentCare Plan
Recent Medical/social circumstances report
HCR-20 where appropriate
Details of a PNC check
Last CPA date and scheduled date for next CPA
Please provide as much information as possible to help us process this referral as quickly as possible.
Acting Chair: Alexis Cleveland Chief Executive: John Lawlor