KENT CLINICAL NEUROPSYCHOLOGY SERVICE REFERRAL FORM
maidstone
To ensure we are complying with trust requirements please complete all sections of the referral.
Client’s Name:
Address:
Post Code:
Telephone Numbers:
Next of Kin:
Next of Kin Contact: / Male / Female:
Date of Birth:
NHS Number:
Marital Status:
Employment Status: ______
Accommodation Status: ______
(ie home owner, homeless, tenant etc.)
Religion: ______
Ethnicity:
White
British □
Irish □
Any other White background □ / Mixed
White and Black Caribbean □
White and Black African □
White and Asian □
Any other mixed background □ / Asian / Asian British
Indian □
Pakistani □
Bangladeshi □
Any other Asian background □ / Black / Black British
Caribbean □
African □
Any other Black background □ / Other Ethnic Groups
Chinese □
Any other ethnic group □
Not stated □
Preferred language:
Is an interpreter required? Yes/No
GP Name:
Address:
Post Code:
Telephone Number: / Care Manager Name:
Address:
Post Code:
Telephone Number:
Consultant:
Other Professionals Involved:
Reason for Referral:
______
Is the Request for:
□  Neuropsychological Assessment/Cognitive Rehabilitation
□  Behaviour Management
□  Psychological Therapy
Brief History Of Current Problems (please include any relevant diagnosis):
Previous Medical And Mental Health History:
Relevant Social Information:
Medication:
Referral Priority:
□  Priority (Immediate intervention required e.g. where there is a risk of placement breakdown due to challenging behaviour or return to work is dependent upon neuropsychological assessment. It is anticipated that prioritised referrals will be seen between 2-4 weeks)
□  Routine (The Service aims to offer routine appointments within 12 weeks)
If priority, what is the reason for this
Are there any particular risks we need to be aware of when dealing with this patient and members of the household in the community? (e.g.: history of aggression, disinhibition, drug/alcohol abuse, other) Yes/No
If yes, a member of the service will contact you for more information
Has this patient consented to the referral? Yes/No
If not, does this patient have capacity to consent to this referral? Yes/No
Has a decision been made that the referral is in their best interests? Yes/No
(In line with the Mental Capacity Act 2005)
Is the client able to travel to the clinic? Yes/No
Referrer Name:
Designation:
Contact Details: ______Date: ______
Please return this form to: Maidstone Neuropsychology Service, Darent House, Hospital Road, Sevenoaks, TN13 3PG. (administration office)
Telephone 01732 228226 (Secretary) Safe Haven Fax: 01732 228205
Or email: