Providing Community Neurological Rehabilitation at:
- Amersham Hospital
- Chalfonts & Gerrards Cross Hospital
- Rayners Hedge
COMMUNITY NEUROLOGICAL REHABILITATION SERVICE
REFERRAL FORM
PLEASE COMPLETE FORM AS FULLY AS POSSIBLE
N.B. Please note that when returning completed referral forms by email, they can only be sent securely from an nhs.net account to the CNRS nhs.net account ()
Patient name and address (affix sticker if available)Telephone:
Date of Birth: Age:
NHS Number:
Ethnicity – please choose option from page 5 / Patient’s GP name and address
Telephone:
Next of Kin name and address
Telephone: / If patient not at usual address – current location?
Telephone:
Recent diagnosis
Date of onset: / Past Medical History
Date of discharge from Hospital/Unit if relevant:
Consultant’s name and contact details:
Reason for referral and Rehabilitation Goals Identified for ongoing therapy:
Is client aware of referral:
Relevant medical management details and interventions (scan results, surgery, investigations, medication…)
PLEASE ENSURE THAT COPIES OF MEDICAL REPORTS AND ANY THERAPY/DISCHARGE REPORTS ARE ATTACHED.
Failure to provide a full medical report could interfere with our ability to process the referral.
Glasgow Coma Scale / Waterlow Score
MRSA status / Known Allergies
Recent Professional Involvement / Name and telephone
District/Named Nurse
Nurse Specialist
Physiotherapist
Occupational Therapist
Speech and Language
Dietician
Psychologist
Care Manager
Current Difficulties / Detail difficulty and Comment
Elimination / Fully continent bowel and bladder
Incontinent: night day
Urinary Bowel
Requires bowel management
Emotion/Behaviour
Cognitive (e.g. Memory, perception, executive function)
Mobility / Independent □
Uses walking aid □ Please specify……………
Non walking □
Please state areas identified for further physiotherapy:
Communication and speech
Aids used – please state / Expressive difficulties
Receptive difficulties
No difficulties
Sleep / Wakes in night
Sleeps through night
Hard to go to sleep
Sleeps during the day
Safety Issues / Cot sides Lives alone
Behaviour History of
Emotional (e.g. suicidal)
Work status / Employed □ Unemployed □
Off sick □ Retired □
Social Situation
Activities of Daily Living / Dependants:
Difficulty performing:
Washing and Dressing Routine □
Toileting Needs □
Transfers from chair/bed etc. □
Domestic Tasks □
Community Living Tasks □
Caring for Dependants □
Leisure Activities □
Work responsibility □
Is client aware of referral?
Request for Professional Assessment – please tick most appropriate
Physiotherapy Clinical Psychology
Occupational Therapy Speech & Language Therapy
Priority: High (initial assessment within 4 weeks)
Routine (initial assessment more than 4 weeks)
Client Referred to Early Supportive Discharge Team for Stroke: YES NO
Expected date of therapy starting:
Expected date of therapy finishing:
Other Services involved on discharge:
Adult Community Healthcare Team Community Services Diabetes
Social Services DNS Heart Orthopaedic
Specialist Nurse (please specify):
Referred by: Job Title:
Address:
Telephone: Date:
Please forward to: Dr Maggie Murphy, Service Lead for Community Neuro-rehabilitation Service, Rayners Hedge, Croft Road, Aylesbury HP21 7RD
Ethnicity Options
White- British
- Irish
- Any other background
- Northern Irish
- Other/Unspecified
- English
- Scottish
- Welsh
- Cornish
- Cypriot (part not stated)
- Greek
- Greek Cypriot
- Turkish
- Turkish Cypriot
- Italian
- Irish Traveller
- Traveller
- Gypsy/Romany
- Polish
- AllRepublics of former USSR
- Kosovan
- Albanian
- Bosnian
- Croatian
- Serbian
- Other Republics of former Yugoslavia
- Mixed White
- Other European
Mixed
- White & Black Caribbean
- White & Black African
- White & Asian
- Any other mixed background
- Black and Asian
- Black and Chinese
- Black and White
- Chinese and White
- Asian and Chinese
- Other/Unspecified / Black or Black British
- Caribbean
- African
- Any other background
- Somali
- Mixed
- Nigerian
- British
- Other/Unspecified
Other Ethnic Groups
- Chinese
- Any Other Group
- Vietnamese
- Japanese
- Filipino
- Malaysian
Any Other Group
- Arab
- North African
- Other Middle East
- Israeli
- Iranian
- Kurdish
- Moroccan
- Latin American
- South/Central American
- Maur/SEyc/Mald/StHelen
Not Known (Not Requested)
Not Known (Unable to Request)
Not Stated (Client Refused)
Not Stated (Client unable to Choose)
Asian or Asian British
- Indian - British
- Pakistani - Caribbean Asian
- Bangladeshi - Other/Unspecified
- Any other background
- Mixed Asian
- Punjabi
- Kashmiri
- East African Asian
- Sri Lanka
- Tamil
- Sinhalese
G:\PCT\Community Neuro Rehabilitation\North MDT\Templates\Referral form (current) 01.04.2015.doc