All parts of this form are mandatory and must be completed in. An electronic copy of this form can be requested by contacting .

For CBT please ring first as there are limited services

CLIENT DETAILS
N.I Number: / NHS number: / Mental Health No: / Care Plan No:
Title: / Status: / Home Telephone Number: / Mobile Number:
Forename: / Surname:
Is this a Wolverhampton Resident? Yes or No
Address:
Postcode:
Date of Birth (DD/MM/YYYY): / / / Gender: Male Female
Ethnicity: / Religion:
1st Language: / Can client speak English: Yes No
Are they a parent of a child under 16: Yes No / Are they working: Yes No
MEDICAL DETAILS
Please state if client is on CPA:CPA non-CPA
GP – Name:
Practice address:
Tel No:
Mental Health needs: Yes No
Give details of support needed diagnosis:[300 Characters, Maximum 4 Lines]
Medication:
REFERRER DETAILS
Referrer Service:
Referrer Name:
Address:
Telephone: / DATE:/ /
Is Service User in agreement to this referral? / Yes No
Does Service User consent to share information with Positive Participation? / Yes No
Has a Risk Assessment been completed? / Yes No
Has a copy of the Risk Assessment been attached with this referral? / Yes No
Blakenhall Community & Healthy Living Centre, Bromley Street, Wolverhampton, WV2 3AS
Phone No: 01902 552275 (soon to be known as the Bob Jones Community Hub)
EMERGENCY CONTACT
Next of Kin- Name:
Relationship:
Address:
Tel No:
OTHER PROFESSIONALS/SERVICES PROVIDING CARE
Main Carer- Name:
Address:
Tel No:
Consultant- Name:
Address:
Tel No:
Social Worker – Name:
Address:
Tel No:
CPN – Name:
Address:
Tel No:
Care Coordinator Name:
Address:
Tel No:
Other Care Provider – Name:
Address:
Tel No:
FURTHER MEDICAL CONDITIONS
Medical/Physical condition: Yes No
Give Details:
Do they have a hearing / visual / speech impairment: Yes No
Give Details:
Diagnose Learning Disability: Yes No
Registered disabled: Yes No
ANY RISK
Risks to self or others: Please consider nature of risk, degree of risk and frequency of risk to self or others
[850 Characters, Maximum 11 Lines]
DETAILS ABOUT MENTAL HEALTH CONDITION & ANY OTHER RELEVANT INFORMATION
[2,000 Characters, Maximum 26 Lines]

Page 1 of 3 Positive Participation Ltd Referral Form