Tarentfort Centre use only

Referral appropriate for TFC?

Discipline(s) allocated to

Outcome of referral

/ 1 TFC waiting list

2 Admission to TFC

3 Referral to another service
4 Liaison
5 Preparation of report
6 Assessment cancelled by patient
7 Assessment cancelled by service
8 Not suitable for admission to TFC

REFERRAL FORM

TARENTFORT CENTRE

DATE REFERRED TO TARENTFORT CENTRE: ………………………………………………………..

SECTION 1:SERVICE USER DETAILS

All areas to be fully completed as this could delay referral acceptance

Service User Name
Alias Names: / D.O.B.
Next of Kin:
(full name, address and relationship to client) / Ethnic Origin :
(See Appendix A)
Marital Status:
(See Appendix A)
Gender: / NHS Number:
National Insurance No:
(If available)
Current Location/Contact details / Last known address:
Type of present accommodation / Prison□
Hospital□
Own home□
Family home□
Community – supported accommodation□
Residential accommodation□
Other (please state)
Confirmed as person with LD? / Any other diagnosis?
Is English the person’s first language? Y/N
If NO, what is the person’s first language? / Are interpreter services and/or other forms of
Communication assistance required? Y/N
Does Patient agree to Referral ? Y/N / FAMILY/CARERS INVOLVED? Y/N
Are they aware of referral?
Does the service user have any medical/physical problems?
Is there any history of contact with thecriminal justice system?
Note dates, charges, outcomes, including those listed in risk factor sections (below)

SECTION 2:REFERRAL AND OTHER AGENCIES INVOLVED

CCG RESPONSIBLE FOR FUNDING / NHS England
Medway
Dartford, Gravesham & Swanley
Swale
West Kent
Thanet
South Kent Coastal
Ashford
Canterbury & Coastal 
Other (please state) / REFERRED BY:
WHICH TEAM? / Prison in-reach□
Solicitor□
Court□
Police□
TPLD – Ashford□
TPLD – Canterbury□
TPLD – Dover□
TPLD – Medway□
TPLD – Thanet□
TPLD – Swale□
TPLD – Shepway□
TPLD – Other□
Current care team (hospital)□
YOT□
Probation□
Socialservices□
Other (please state) / NAMES OF RESPONSIBLE CLINICIAN (if applicable) and NAME OF MHLD TEAM OR CMHT TEAM
Is the referral the outcome of multidisciplinary discussion? Y/N
Any other agencies involved?
(e.g. day/employment services; probation etc)
Please list with contact details

SECTION 3: REASON FOR REFERRAL

Reason for referral / Assess for admission to TFC□
Risk assessment□
Placement advice/Access□
Management advice□
Legal□
Other (please state)
Date patient was last seen by yourself or MHLD/CMHT Team.

CURRENT SITUATION

What are the current concerns?
Description of current behaviours and any recent changes:
Description of current mental state and any recent changes:
Brief summary of Placement history / Lifestyle
Any recent life events? (e.g. bereavement, move, change of activities)
Social Situation: Include significant others, culture-specific needs

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SECTION 4: RISK FACTORS/RISK MANAGEMENT: BRIEF DESCRIPTION FOR EACH WHERE RELEVANT

Aggressive behaviour
Self-harm
Self-neglect
Absconding
Arson/fire risk
Sexually inappropriate behaviour:
Other areas of vulnerability:
Substance misuse

Appendix A: Demographic Detail

Please verify the following with Service User:

Ethnicity /
  • Asian / Asian British - Indian
  • Asian / Asian British - Pakistani
  • Asian / Asian British - Bangladeshi
  • Asian / Asian British - Any other Asian background. Please specify:
  • Black / Black British - Caribbean
  • Black / Black British - African
  • Black / Black British - Any other black background. Please Specify:
  • Chinese / Other Ethnic Group - Chinese
  • Chinese / Other Ethnic Group -Any other. Please specify:
  • White - British
  • White - Irish
  • White - Any other. Please specify:
  • Mixed - White & Black Caribbean
  • Mixed - White & Black African
  • Mixed - White & Asian
  • Mixed - Any other mixed background. Please specify:
  • Not Stated –Service User Chooses to Not disclose

Marital Status /
  • Civil Partnership
  • Divorced/Person Whose Civil Partnership has been dissolved
  • Married
  • Service User Chooses to Not disclose
  • Separated
  • Single
  • Widowed/Surviving Partner

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