Assertive Outreach Referral Form

CITY ASSERTIVE OUTREACH SERVICE

NECESSARY CONDITIONS

Name of Service User: Date of Birth:

Date: Consultant Psychiatrist:

Team:

Name of worker completing this assessment:

Designation:

In order to be considered for an Assertive Outreach Service assessment all of the Necessary Conditions must be met.

CRITERION 1 – NECESSARY CONDITIONS

(Please Tick)
1. / The Primary diagnosis must be one of serious and enduring mental illness, having a diagnosis of a psychotic illness such as Schizophrenia, Bipolar Psychosis, or Psychotic Depression.
2. / A history of high use of inpatients, history of high use intensive home based care, has been admitted to a mental health in-patient unit on at least two occassions or over a six month duration in the past two years or a history of high use intensive based care.
3. / Be on Enhanced CPA level.

AND fulfil a combination of the following (please tick if fulfilled)

CRITERION 2 – RISK FACTORS

1. / Failure to Engage with the Service: Has this person failed to engage with the Service?
2. / History of violence or of persistent offending: Does the person have a recorded and persistent history of violence or of persistent offending?
3. / At risk of persistent self-harm or neglect: Does the person persistently neglect or self-harm?
4. / Poor response to treatment: Has this person failed to respond to treatment?
5. / Combined substance misuse with serious and enduring mental illness: Does this person have a dual diagnosis?
6. / Has been detained under the mental Health Act 1983 on at least one occasion in the past two years

The evidence for fulfilling any of the above criteria must be easily accessible within the case file.

Signed by:______

Care Co-ordinator / Keyworker

N/B: Please could you include the Inter-Agency Assessment Form, current CPA Care Plan, Comprehensive Risk Assessment and Contingency Plan.

LEICESTERSHIRE PARTNERSHIP NHS TRUST

CITY ASSERTIVE OUTREACH TEAMS

REFERRAL FORM

SERVICE USER PERSONAL DETAILS

Surname: / Address:
Forename(s):
Preferred Name:
Date of Birth: / Post Code:
Gender:MaleFemale / Telephone Number:
First language: / Mobile Number:
Preferred Language: / Is an interpreter required:Yes  No 
National Insurance No: / Ethnic Category: Complete attached sheet
Maracis No: / Religion:
Care First No: / Marital Status:
Has the referral been discussed with Service user (if no state reason)
Yes  No  / Current Consultant Psychiatrist:
At time of referral, is service user at
Home address
Inpatient: / If inpatient please give name of ward:

MAIN CARERS/SIGNIFICANT OTHERS

/ REFERRERS DETAILS
Name: / Name:
Relationship: / Involvement with Service User:
Next of Kin: / Address:
Address (if different to patient’s):
Telephone Number:
Interpreter Needed / first language: / Signature:
Telephone Number: / Date:

NEAREST RELATIVE (MHA 1988):

/ LEGAL STATUS
Name: / Informal: Yes  No 
Address: / If no: what section
Section 117:Yes  No 
Telephone Number: / Supervised Discharge (S25)Yes  No 
RMO Name: / Care Co-ordinator:

GENERAL PRACTITIONER

/ OTHER INVOLVED WORKERS/AGENCIES
Name: / 1. Name:
Address: / Telephone Number:
2. Name:
Post Code: / Telephone Number:
Telephone Number:
3. Name:
Telephone Number:

DIAGNOSIS

Diagnosis:
ICD 10 Code:

Ethnic Category Table

GROUP / CODE / Please Tick / DESCRIPTION
White / A / British
B / Irish
C / Any other White background
Mixed / D / White and Black Caribbean
E / White and Black African
F / White and Asian
G / Any other mixed background
Asian or Asian / H / Indian
British / J / Pakistani
K / Bangladeshi
L / Any other Asian background
Black or Black / M / Caribbean
British / N / African
P / Any other Black background
Other ethnic / R / Chinese
Categories / S / Any other ethnic category
Not stated / Z / Not stated

LIVING GROUPS

Lives Alone
Lives with Partner / Spouse
Lives with OtherPlease state who:

TYPE OF ACCOMMODATION

Owner / OccupierHouse
Rented PropertyFlat

BENEFITS

Income SupportDLA
Incapacity BenefitMobility
Housing BenefitPersonal Care

FINANCIAL ASSESSMENT (Including Debts)

NUMBER OF ADMISSIONS

(Please state how many of these have been formal)

HISTORY OF CONTACT WITH MENTAL HEALTH SERVICES

Is the person still engaged in the service?Yes  No 
If yes, how long was the client in touch with psychiatric services prior to referral:
More than 1 year
1-5 years
More than 5 years
Do they attend outpatient’s appointments?Yes  No 
Do they attend appointments with others ie GP, Probation Officer?Yes  No 
Is there anyone else they see regularly ie friends / family?Yes  No 
If so who?
History of contact with other services eg voluntary services?Yes  No 
History of substance misuse?Yes  No 

RESPONSE TO TREATMENT

Has the person failed to respond to treatment?Yes  No 
Please give a brief summary of treatment including current package

CONCISE MENTAL HEALTH HISTORY: INCLUDING RISK INDICATORS

PRESENT MEDICATION

(Please list current medication and provide details of service users concordance)

HAVE THERE BEEN DIFFICULTIES WITH ENGAGEMENT IN THE PAST

(e.g. Non Acceptance of Home Visit, Medication Regime, Out-Patient Appointments – Please complete enclosed engagement measure)

PRESENT

(Please give an outline of present need and identify in what way it is though the Assertive Outreach Service may me able to help)

Signed (Referrer)

NB: Please include the CPAInter-Agency Form, current CPA Care Plan, Comprehensive Risk Assessment and Contingency Plan. If these items are not included with this referral, assessment may be delayed.

INITIAL RISK SCREENING TOOL
Full Name / Maracis No / NHS No
Address: / Consultant
Religion
Post Code: / Ethnic Origin
Tele No: / First/Pref Lang
Preferred Name: / Marital Status
DoB / AGE / Interpreter required / YES / NO
RISK FACTORS
Mark with an “x” when responding / Yes / No / Don’t know / Info
source
Self-Harm/Suicide
History of self-harm/para-suicide
Current thoughts or plans indicating a risk of self-harm or suicide
Mental illness (e.g. depression, psychotic illness)/personality disorder/dementia
Current problems with alcohol or substance abuse
Any expression of concern (especially from a relative or carer) about risk of self-harm/suicide
Harm to others
History of harm to others
Current thoughts, plans or symptoms indicating risk of harm to others
Current behaviour suggesting risk of harm to others
Current problems with alcohol or substance abuse
Any expression of concern from others about risk of harm to others
Evidence of arson and fire-setting
Self neglect
Fluid/dietary problems
Personal hygiene problems
Risk of accidents, including falls
Untreated physical illness
Non-compliance with medication
Relapse and disengagement risk
Alcohol/substance misuse
Homelessness
Inability to manage personal affairs
Exploitation/Vulnerability
Exploitation
Impulsive behaviour
Grandiose ideas
Wandering/missing from expected location
Access/cooperation
Anti-social behaviour
Absconding [inpatient setting only]
Could any of the above risks impact on children:
... in the immediate family home?
... through extended family contact?
... through informal contact with children in the community?
Could any of the above risks impact on vulnerable adults:
... in the immediate family home?
... through extended family contact?
... through informal contact with vulnerable adults in the community?
Are there any issues that may impact on the service user’s fitness to drive? Please refer to the DVLA’s “At A Glance” guide to the current medical standards of the fitness to drive (
Is a fuller assessment of risk indicated? If no, please give reasons below. / YES / NO

[NB All enhanced level CPA, all Continuing Care, and all cases where high risk issues are evident or suspected should prompt a full risk assessment]

Completed by: / Designation:
Signature: / Date & Time:

If a fuller risk assessment is not required please give reasons, continuing on a separate sheet if necessary:

* INFORMATION SOURCE - KEY

User direct / SU / Carer(s) / C
Other professionals/agencies / A / Reports in files / F
Own direct knowledge of the case / K / Observation / O
1. IF A FULLER RISK ASSESSMENT IS NOT REQUIRE PLEASE GIVE REASONS BELOW:
2. FURTHER DETAILS OF RISKS WITH STAFF VISITING SERVICE USER I.E. NEED TO VISIT IN TWO’S MALE OF FEMALE WORKER NEEDED, RISK WITH HOME ENVIRONMENT, HEALTH AND SAFETY ISSUES etc.

Engagement Measure (Observer version)

Date Rated:

Clients Name:Rater:

Therapist’s length of involvement with client:

For each area please circle the number that best describes your client at the current time. Terminology. ‘Treatment’ refers to the whole treatment package, not just medication. ‘Therapist’ refers to the person most involved with the client, this will usually, but not always, be the keyworker.

Area 1) Appointment keeping

(include attendance of outpatient appointments and keeping other appointments i.e. being at home when arranged).

a.Without Support: (i.e. without key-worker bringing them)

1 / 2 / 3 / 4 / 5
Never keeps appointments / Rarely keeps
Appointments / Sometimes keeps appointments / Usually keeps appointments / Always keeps appointments

b.With Support: (i.e. key-worker bringing client to appointments)

(Note: Even if client attends without support, please rate what their attendance would be like with support)

1 / 2 / 3 / 4 / 5
Never keeps appointments / Rarely keeps
Appointments / Sometimes keeps appointments / Usually keeps appointments / Always keeps appointments

Area 2) Client-therapist Interaction

Quality of Relationship

(The extent to which the client relates well with therapist, giving rise to a positive atmosphere during sessions)

1 / 2 / 3 / 4 / 5
Never relates well with therapist / Rarely relates well with therapist / Sometimes relates well with therapist / Usually relates well with therapist / Always relates well with therapist

Area 3) Communication / Openness

(The extent to which client volunteers relevant personal material, is open in discussing feelings, problems and current situation)

a. Personal feelings (i.e. anger, depression etc)

1 / 2 / 3 / 4 / 5
Never discusses personal feelings / Rarely discusses personal feelings / Sometimes discusses personal feelings / Usually discusses personal feelings / Always discusses personal feelings

b.Personal problems (i.e. difficulties in current life situation)

1 / 2 / 3 / 4 / 5
Never discusses personal problems / Rarely discusses personal problems / Sometimes discusses personal problems / Usually discusses personal problems / Always discusses personal problems

c.Symptoms

1 / 2 / 3 / 4 / 5
Never discusses symptoms / Rarely discusses symptoms / Sometimes discusses symptoms / Usually discusses symptoms / Always discusses symptoms

Area 4) Client’s perceived usefulness of treatment.

1 / 2 / 3 / 4 / 5
Never perceives treatment as useful / Rarely perceives treatment as useful / Sometimes perceives treatment as useful / Usually perceives treatment as useful / Always perceives treatment as useful

Area 5 Collaboration with treatment

(The extent to which client agrees to proposed intervention, as stated in their care plan, and is involved in carrying it out i,e keeping diaries, practising relapse drills etc)

a. Agreement with treatment

1 / 2 / 3 / 4 / 5
Never agrees with proposed intervention / Rarely agrees with proposed intervention / Sometimes agrees with proposed intervention / Usually agrees with proposed intervention / Always agrees with proposed intervention.

b.Passive involvement in treatment

(Passive involvement: Client goes along with treatment)

1 / 2 / 3 / 4 / 5
Is never involved in proposed intervention / Is rarely involved in proposed intervention / Is sometimes involved in proposed intervention / Is usually involved in proposed intervention / Is always involved in proposed intervention.

c.Active involvement in treatment

(Active involvement: Client clearly wants to involve themselves in the treatment process)

1 / 2 / 3 / 4 / 5
Is never actively involved in intervention / Is rarely actively involved in intervention / Is sometimes actively involved in intervention / Is usually actively involved in intervention / Is always actively involved in intervention

Area 6) Compliance with medication

(Extent to which client agrees to take medication and will take it freely)

1 / 2 / 3 / 4 / 5
Never complies with medication / Rarely complies with medication / Sometimes complies with medication / Usually complies with medication / Always complies with medication

ASSERTIVE OUTREACH REFERRAL FORM

CHECK LIST

To ensure a prompt processing of this referral please ensure that you have completed the following accurately.

1.Referral Form

2.Inter agency CPA Assessment

3.Current CPA Care Plan

4.Comprehensive Risk Assessment and

Contingency Plan

If these items are not included with this referral, the assessment may be delayed

OFFICE USE ONLY

Date Received:______

Referral forwarded onto:-

City East Team

City West Team

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