AND SUPPORT SERVICE (EMDASS)
REFERRAL FORM /
DATE OF REFERRAL: ${Todays_date} / SCR Status: / SCR with AI Status:
PATIENT DETAILS
Title: Last Name: First Name:
NHS No: Date of Birth: Age: Sex :
Address:
Preferred No: ☐Home Tel No: Patient consents to message being left Y☐N☐
Preferred No:☐Mobile Tel No: Patient consents to message being left Y☐N☐
Ethnicity: Language: …………………………………… Interpreter Required:Y☐N☐
Learning Disabilities: Y☐N☐ Does the patient require reasonable adjustments to be made? Y☐ N☐
If so, please state what is required: ……......
REFERRER DETAILS
Referring GP: GP Signature: ………………………………………….……...
Practice: Practice Address :
Practice Telephone: Practice e-mail:
Alternative Contact No.:……………………………………………….. Alternative Email:………………………………………..…………………..
(For referring GP if urgent contact required for this referral)
CONSENT: This referral has been discussed with the patient and the patient consents to relevant information being shared with the service provider ☐
Spouse/Carer’s Name
Relationship to Patient
Address
Contact Telephone Number / Consent to leave Voicemail Y ☐N ☐
Is this a private or a work number
Previous diagnosis of dementia? / Y ☐ N ☐ / If yes, please send/attach details:
REFERRAL DETAILS
REASONS for Referral:
SUMMARY of current memory/cognition related problems (including duration and progression):
SUMMARY of current & past medical conditions
(attach current medication)
Any additional Information: (A covering letter will be appreciated)
SCREENING TEST RESULTS REQUIRED FOR REFERRAL
Physical Examination / Pulse : / BP: / Abdomen:
Chest: / Neurological:
Blood Tests
Please indicate when abnormal / FBC / ESR / Folate
B12 / Glucose / Cholesterol
Thyroid / Renal function / Liver function
Calcium
Others (if any): / ECG
This form can be sent by e-mail it to: or to Single Point of Access, Trust Head Office, 99 Waverley Road, St Albans AL3 5TL. Tel:0300 777 0707/Fax: 0300 777 0808
Please note that this form is secure if it is sent FROM an @nhs.net email address TO an @nhs.net email address.
If you have any concerns about emailing it back to us, please post to the above address.
Guidelines to completing REFERRAL Forms (Revised June 2012)
INCLUSION CRITERIA
- Individuals (including younger people) with memory problems or declining cognitive function, which may have been noticed by carers or relatives or other close associates. This may be evidenced by impaired memory, significant change of behaviour and/or other psychiatric symptoms.
- Individuals (regardless of age) who have never had a formal diagnosis of dementia, even though they may be engaged with mental health services in the past.
- Symptoms that warrant a referral include; memory concern, unexplained changes in mental health and changes in ability to perform activities of daily living.
EXCLUSION CRITERIA
- Individuals who already have a diagnosis of dementia, and who are existing or past service users of the Specialist Mental Health Team for Older People with a care plan in place.
- Individuals who have very complex and urgent care needs and who are at the point of crisis and break down.
- Individuals who choose to not proceed with assessment.
- Individuals presenting predominantly with signs brain damage due to head injury, stroke, alcohol abuse etc.
PRIOR TO REFERRAL - SCREENING TESTS AND RESULTS REQUIRED
Full Physical Examination (including Neurological) and exclusion of delirium due to underlying medical conditions including chest and urinary tract infection
Blood Tests to include – FBC, Folate, Glucose, B12, Thyroid, Renal and Liver Functions, lipid profile
PS: ECG and chest X-ray may be requested following initial assessment. We would organise CT scan when necessary.
Please note:
- Patients referred to EMDASS may be assessed and managed by any member of the locality SMHTOP, depending on the urgency of the referral and need of the patientand
- Patients requiring antidementia medication, prescribed elsewhere, will not get the prescription unless assessed and accepted by the local EMDASS Team