Working Together to Benefit our Community

REFERRAL FORM

Community Team for People with Learning Disabilities

CONFIDENTIAL

Please complete and return this form to:

Referral Administrator, CTPLD, Castlewood Offices, Tickenham Road, Clevedon, BS21 6FW.

Tel 01934 427600 Fax: 01934 427321

If you need help filling in this form please contact us on the above telephone number.

Name:
Address:
Tel no:
Date of Birth:
GP:
GP Address:
GP Tel no:
Consultant or other Specialist Service:
Relevant Medical Information:
(Reason for referral on next page)
Ethnic Origin:
Preferred Language:
Social Worker/Care manager:
Funding Authority:
Funding Authority Address:
Funding Authority Tel no: / Referred by:
Address:
Date:
Tel no:
Non urgent
Urgent
Please state why (see criteria):
Please note referral criteria & response guidelines:
Urgent: if referee/ others are at immediate risk of significant harm or immediate risk of placement breakdown. Response : 2 working days
Relative/Carer/Next of Kin and contact details
Name of Keyworker/Contact :
Relationship to referee:
Address:
Telephone no:
Best times to call:
For children only (under 18 years)
Has permission of parent/guardian been received in writing? Yes No
Please explain your need / reason for referral:
(e.g.care or support/health issues/mental health issues/isolation and loneliness/employment support/money/accommodation)
Is the service user aware of the referral? Yes / No
(if no please explain)
Is there anyone that the service user does not wish to be informed of the referral? Yes / No
(If Yes - please explain)
Can you answer any of the questions below:
Yes/No/Don’t Know
Previous CTPLD Eligibility Assessment done
Previous Social Care assessment
Are there any safeguarding concerns
Have the CTPLD been involved before
Is there a Person Centred Plan
Postural Management Plan
Eating and Drinking Instructions
Communication Guidelines
Positive Behaviour Management Plan
Is there a Care Package/support plan
GP last seen (Date)
(Continue on a separate piece of paper if necessary)
Completed by:
Name / Designation / Date:

RISK ASSESSMENT CHECK LIST

(To be completed by ALL referrers)

Name of Service User: / Completed by:
Date of birth: / Profession:
Address: / Date of referral:
Has this service user been seen by CTPLD before? Y / N

Should two workers attend for the first visit? Y/N

Please explain why

If there are indications that there is a risk or potential risk present in the following areas, please circle YES or NO. If YES, then complete the details in the appropriate sections. Referrersmay attach separate specific risk assessments if these have been done.

Regarding the Person’s Environment
Parking/Access
Physical hazards (e.g. hazardous surfaces)
Lighting
Lifts or stairways
Electrical Safety
Other environmental hazards
(e.g., dogs, snakes, infection issues/concerns) / YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Regarding the Person:
Behaviour of service user or carer (including violent incidents)
Mental health problems (e.g. acute anxiety states)
Physical health problems
Transport or Mobility issues
Communication/Dietary/Medication issues
Manual Handling Risk
Infections/open wounds etc / YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO

1 | Page

Version 04.08.2016