CRHT Referral Form Bedford

Service User Details:

(If a copy of the CPA 1 is made available please dismiss)

Forename: / Surname:
Date of Birth:
Title: / Known Alias:
MPI No: / NHS No:
Current Address:
Post Code: / Contact No’s:
Gender: / Ethnicity:
Special requirements:
(e.g: Communication barriers) / Religion:
Care Coordinator: / CPA Status:
Marital Status: / N.O.K. Contact No:
N.O.K Name:
(State Relationship) / N.O.K Address
G.P Name: / G.P Address
G.P. Contact No: / G.P Post Code:

Mid & North Beds Crisis Resolution and Home Treatment Team

Current presenting problems:

(Brief description of problems(s) including currently psychiatric symptoms)

Past psychiatric history:

(Previous admissions / engagement with any other services / non-compliance)

Physical Health / Substance Misuse:

(Brief description of problem(s) including current medication, BP, allergies, smoking status, BMI)

Mid & North Beds Crisis Resolution and Home Treatment Team

Risk of harm to self, including self-neglect:

(Please outline any risk behaviours, current ideation and previous attempts)

Risk to others, including children / staff:

(Have they stated they want to harm others? No. Children in the household? If yes, please

state who and why – any agencies involved ie: Child Protection)

Forensic history/details:

(Please list cautions and sentences if known and other agencies involved – ie: MAPPA, probation)

Mid & North Beds Crisis Resolution and Home Treatment Team

FOR CMHT USE ONLY

Frequency of Current Contact
Last Contact Date
Date of Las Medical Review

Referrers Details:

Name: / Designation:
Contact No: / Signature:
Date of Referral: / Time of Referral:
Is the person aware that you are making this referral? YES / NO

Crisis Resolution and Home Treatment Team Only:

Referral Received:
(Time, Date& Assessor)
Triage Assessment Completed:
(Time, Date & Assessor)
CRHT Assessment Complete:
(Time, Date & Assessor)

Mid & North Beds Crisis Resolution and Home Treatment Team

Bedford CRHT Telephone Triage / Screening Assessment:

Name: / DOB:
Date of
Screening: / Time of
Screening:
Name of Assessor:
Current
Problems:
(As reported by
Service User / Carer)
Current risks of
Suicide/self-harm:
(Passive/active
Suicidal ideation, intent/plan, protective factors, previous attempts, frequency & intensity of suicidal thoughts, plans for the next few days, who is at home with the S.U, what support is at home, any current alcohol drug use)
Risk to others:
(Staff, targeted groups / individuals, risk to children – include historical events)

Mid & North Beds Crisis Resolution and Home Treatment Team

Outcome of Telephone Assessment

Triage Priority:
(face to face assessment dependant on RAG status of telephone screen – expected time of CRHT assessment agreed)
If CRHT assessment NOT appropriate:
(Compulsory Decision Monitoring/MDT discussion with Professional Leads and / or medics stating rationale for outcome)
Name of Clinician decision
Reviewed / Shared with:
Signature of Clinician decision Reviewed / shared with:
FINAL OUTCOME:
(Please tick one of the following) / GP / ASPA / CMHT / MHA
Referrer informed of outcome / Time / Date:

Mid & North Beds Crisis Resolution and Home Treatment Team