Lisburn Ymca Referral Form

LISBURN YMCA REFERRAL FORM

Client Name: / Date of birth:
Address and Telephone:
Next of Kin
Name:
Address:
Telephone: / Relationship to client:
GP Name and Address:
OTHER HEALTH PROFESSIONALS/AGENCIES INVOLVED (e.g. Speech and Language, Physiotherapists, Teachers, Careers Advisor, Employment Officer)
Type of Referral: (Please tick)
Self/ Family / Teacher/College Tutor
GP/Consultant / Social Worker
CPN / Voluntary/Community
Organisation
Other referral source:
Referral Agent Information
Name
Job Title
Organisation
Address
Post Code
Telephone No. Email Address
Reason for referral (needs identified)
Type of support required (specific recommendations to include individual work/social activities/)
What other services are the client engaged with ? Please specify support provided.
INFORMATION REGARDING DIAGNOSIS(Mental ill health, learning disability, physical disability, Autistic Spectrum Disorder)
Does the client have a confirmed mental health diagnosis? Yes / No
Does the client have a confirmed learning disability diagnosis? Yes / No
Does the client have a confirmed ASD diagnosis? Yes / No
Does the client have a confirmed physical disability? Yes / No
In the space below please provide information regarding the condition
Does the client take medication?
If yes, please state the type of medication, what it is for and any possible side effects.
Does the client have a Risk Management Plan? Is the plan attached to the referral form?
Risk and Needs Indicator: Please use the section to highlight any risks or needs not previously stated
Is there a history of self harming behaviour? YES NO
If yes, please provide details including date of last incident.

Is there a history of suicidal ideation and/or suicide attempts? YES No
If yes, please provide details including date of last incident and any identified triggers.
Is there any history of physical/verbal abuse or aggression? YES NO
If yes, please provide details including date of last incident and any identified triggers.
Is there any history of abuse of prescription/recreational drugs and/or alcohol? YES NO
If yes, please provide details including date of last incident.
Is there any history of sexually inappropriate behaviour? YES NO
If yes, please provide details including date of last incident.
Has the client been convicted of any criminal offences? YES NO
If yes, please provide details including date of last incident.
Referral Agent Signature: ______

Is the client in agreement to the referral? YES NO
Date completed: ______
Project Co-Ordinator’s signature ______
Date ______
Proposed action to be taken ______

Completed applications to;

Carolyn Jamison

Lisburn YMCA

28 Market Square

Lisburn, BT28 1AJ.

02892670918

Email: