Beh Triage Services

BEH TRIAGE SERVICES

Barnet / 2nd Floor, Dennis Scott Unit, Edgware / 0208 702 5000
Option1 / 0208 951 2128 /
Enfield / Crown Lane, Enfield / 0208 702 5000
Option 2 / 0208 362 0489 /
Haringey / N and O Block, St. Ann’s Hospital / 0208 702 5000
Option 3 / 0208 442 6705 /
Referral form for non-urgent, routine assessments to the Triage service
*Date of referral:
*NHS No: / *Title:
*Surname / *First name
*D.O.B: / *Gender: / MALE / FEMALE
*Address 1:
Address 2:
Address 3: / *Post Code:
*Home Tel: / *Mobile:
*Marital Status:
*Does client have children
under 18 years? / Yes: / No: / Unknown:
*Ethnicity
(Please refer to ethnic coding sheet attached):
*Interpreter required? / Yes / No
If YES please state language:
*GP Name / *Referrer details if not GP
*GP Address details / *Name:
*Address details:
*GP Tel: / *Tel:
Current Medication(s) With dosage and frequency
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Presentation – Symptoms/duration
Risk Features: Alcohol & illicit drugs – quantities used, frequency, duration of use, ever injected? Any withdrawal symptoms from alcohol or any other drugs?
Treatment/Services already involved:
History: Previous diagnosis, Admissions, Any self-harm? Cautions & convictions
Influencing Factors:Housing, current mental state, drugs& alcohol use, forensic history
Living/Social Circumstances: accommodation – rented/owned, current employment, social support networks incl. Day centres, clubs etc. Financial circumstances incl. Income/benefits and any debts, attending any courses etc.
Dependants: Please specify if dependants under 18 years, or under 22 in full time employment.
Any other further information/;

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BEH TRIAGE SERVICES

ETHNICITY CODING GUIDANCE

In accordance with the Trust’s policy on ethnic monitoring, we collect information about the ethnicity of people who use all mental health services. The information collected is used to address any inequalities and to ensure that the needs of ethnic groups are being met.

Information about ethnicity is held confidentially in accordance with the Data Protection Act. Whilst we would encourage you to provide this information, the Client is not obliged to do so. If they do not wish to provide this information please enter “Not stated/refused” on the Ethnicity form.

Please enter the ethnic group with which the Client identifies:

Asian or Asian British – Bangladeshi
Asian or Asian British – British
Asian or Asian British – Caribbean Asian
Asian or Asian British – East African Asian
Asian or Asian British – Indian
Asian or Asian British – Kashmiri
Asian or Asian British – Mixed Asian
Asian or Asian British – Pakistani
Asian or Asian British – Punjabi
Asian or Asian British – Sinhalese
Asian or Asian British – Sri Lanka
Asian or Asian British – Tamil
Asian or Asian British – Any Other Background
Asian or Asian British – Other / Unspecified
Black or Black British – African
Black or Black British – Caribbean
Black or Black British – Somali
Black or British Black – British
Black or British Black – Mixed
Black or British Black – Nigerian
Black or British Black – Somali
Black or Black British – Any Other Background
Black or British Black – Other / Unspecifie
Mixed – Asian and Chinese
Mixed – Black and Asian
Mixed – Black and Chinese
Mixed – Black and White
Mixed – Chinese and White
Mixed – White & Asian
Mixed – White & Black African
Mixed – White & Black Caribbean
Mixed – Any Other Background
Mixed – Other / Unspecified
Not Stated
Refused (I do not wish to give this information) / Other Ethnic Groups – Chinese
Other Ethnic Groups – Filipino
Other Ethnic Groups – Japanese
Other Ethnic Groups – Malaysian
Other Ethnic Groups – Vietnamese
Other Ethnic Groups – Any Other Background
White – Albanian
White – All Republics of former USSR
White – Bosnian
White – British
White – Cornish
White – Cypriot (part not stated)
White – English
White – Greek
White – Greek Cypriot
White – Gypsy / Romany
White – Irish
White – Irish Traveller
White – Italian
White – Kosovan
White – Mixed White
White – Northern Irish
White – Other European
White – Other Republics of former Yugoslavia
White – Polish
White – Scottish
White – Serbian
White – Traveller
White – Turkish
White – Turkish Cypriot
White – Welsh
White – Any Other Background
White – Other / Unspecified
Any Other Group:
Please state______

IN ADDITION TO COMPLETING THIS FORM WE REQUEST YOU TO ATTACH THE PATIENT SUMMARY (ENCOUNTER RECORD) WITH THIS REFERRAL OR CLEARLY STATE THAT YOU WILL NOT BE SENDING THIS.

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