Silverlink ID No:
Address:
Date of Birth: / Gender:
Telephone: / Referral Date:
GP Details:
Is an interpreter required? If so what language:
CAMHS Contact Name: / Contact Number:
Peer Support Worker Name: / Contact Number:
SUMMARY OF NEEDS
- Describe main problems
- Give reason for referral
- Include crisis plan if in place
RISKS & ISSUES
If any Safeguarding risks are identified report them here
- What risks does the young person present? (e.g self-harm, suicide, safeguarding adults, safeguarding children). Include information regarding plans, intent, actions, and protective factors
- Has a crisis plan been agreed? Does the person have details for the Crisis team?
- Give example of past incidents and how they relate to mental state
- What measures have been taken to reduce the known risks?
- What risks (if any) remain unmanaged?
CURRENT MENTAL HEALTH
- What are the young persons’ current symptoms/experiences?
- Have there been any major changes?
MENTAL HEALTH HISTORY
- Give details of history at the time of referral to Adult Services
- Current medication
- Has the person been treated in specialist services before?
- Are there any factors which trigger an episode of care?
- Is there any family history of mental health problems?
PHYSICAL
Review physical health needs
- Does the young person have any long term physical health conditions?
- Is there a Specialist involved who will need to be communicated with to discuss treatment plans?
- Are you aware of any new signs or symptoms which may need to be investigated?
SUBSTANCE MISUSE
- Does the young person misuse substances? If so, what and how much (define in weight or financial terms)? How does this affect risk?
- Does this affect the young person’s ability to give a clear account of their problems and functioning?
- Is the young person open to drug/alcohol services? Does the young person need referring?
FORENSIC
- Does the young person have a forensic history? If so please give any details you are aware of, including whether they are known to probation or MAPPA
HOUSING/ENVIRONMENT
- Who lives with the young person?
- Does the young person need support to move or live more independently?
PERSONAL CARE/DOMESTIC ROUTINE
- Does the person need any help/support with any self care functions?
WELFARE AND BENEFITS
- Does the young person have any worries of a financial nature?
- Does the young person currently receive benefits?
EMPLOYMENT/EDUCATIONAL/OCCUPATION
- Is the young person in education and attending regularly?
- Is the young person currently unable to work due to mental health issues?
- Does the young person want to work/volunteer?
- Does the young person have any specific education aims?
- What does the young person do to keep occupied? Hobbies & interests?
FAMILY/SUPPORT NETWORKS
- What support networks does the young person have?
CARING RESPONSIBILITIES
- Does the young person have any caring responsibilities for children or a vulnerable adult? (if yes, gives names and ages)
- Do they have access to any children?
- Are there any identified risks with this access?
PSYCHOLOGY/PSYCHOTHERAPY
Note include IAPT treatment in this section
- What IAPT interventions have been given to date?
- How many IAPT sessions have been given?
- Current outcome measure scores (GAD7, PHQ9)?
- Any improvement / deterioration during IAPT intervention?
CULTURE/ETHNICITY
- Has the young person always lived in this country?
GENDER/SEXUALITY
- Does the young person have any issues as regards gender, sexuality, sexual health, or current / past abuse?
- Is the young person in a positive relationship at the moment?
- Has the young person ever had any difficulties developing or maintaining relationships in the past?
SPIRITUALITY
- Does the young person have a strong faith? How does it help the young person?
ASSESSMENT OUTCOME:
To be completed after discussion at referral meeting
Referral Accepted / Yes / NoIf not, rationale for not accepting:
T
Team Transferred to:
Allocated Worker Name:
Allocated Worker Contact Details:
Assessor Name:
Job Role:
Assessment Date: