NHS Number:

GP Referral to WLMHT Adult Mental Health Services

Patient Details / Referring Doctor Details
Name / Name
Address / Address
Telephone / Telephone
DoB / Fax
NHS Number / E-mail
Gender
Marital Status / Date of Referral
Interpreter Required / Yes No / Language
Assistance with Booking Required / Yes No / Ethnicity
Next of Kin/ Carer details and phone number
Referral Priority
If you think this referral requires rapid response within 24 hours, please contact our services directly: CMHT/Assessment Service 9am to 5pm Mon-Fri. Out of hours Hounslow Home Treatment Team can be contacted via West Middlesex Switchboard 0208 560 2121, Bleep 385.
High Priority (assessment within 2 weeks)
Please give reason for high priority………………………………………………………………………….
Soon (assessment within 6 weeks)
Routine(assessment within 11 weeks)
Final priority will be determined by the assessment service.
Referral to (e.g. hospital; community service, specialty and clinician)
Specifyspecialty/ department:
Specify destination and address:
Accommodation status
Owner Occupier / Living with friend/ relative
Council Tenant / Homeless
Housing association Tenant / NFA
Private Tenant / Other (please describe)
Employment status
Employed: / Unemployed:
Other including in education and training (please describe)
Other details
Is the patient aware of the referral? Yes No
If not, why?
Are they currently under a safeguarding adult/children investigation?Yes No
If yes please give details.
Is this person a parent or carer of children under18?Yes No
If yes please give details.
Reason for Referral - What is wanted from the service?
Are you concerned about a memory issue?Yes No
If yes please give details.
Presentation and Management to date
Current medication (dose & start date)
Risk assessment: current risk of harm to self and others
Past Psychiatric & Risk history (Please attach any relevant correspondence)
Relevant medical/surgical history/ substance use
Other Information
Date of last physical health check: / Physical screening test results:
Known allergies and side effects:
Please provide details of other services currently involved in this case:
Referrers’ Signature: / Date:

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