Stroke Early Supported Discharge Referral Form

Patient’s name / DoB
Addressor affix label / NHS No
Ethnicity
GP Name
Postcode / GP Surgery
Telephone / GP Telephone
Next of Kin name & relationship
Next of Kin telephone
Referring Hospital / Date of admission
Ward / Ward Tel No
Has this patient had a stroke? / YES/NO / Date of Stroke
CT/MRI date & result
Consultant name
Main deficits
Estimated Discharge Date / No of bed days saved through ESD input
Referral to:OT PT SLT NURSING 
ACHT: Does the patient have ACHT/Reablement/POC needs? YES/NO
Has this been arranged? YES / NO
How many visits per day? ______This is for :______
Social History / Accommodation
Lives alone  or lives with
Any dependents
Previous mobility
Previous ADLs
Previous support/agencies
Work/interests/hobbies / House  Bungalow  Flat  RH  NH 
Access
Keysafe
Stairs
Adaptations
Past medical history / Medications at Discharge
Summary of inpatient assessment and therapy progress
Include outcome measures & send copies of assessments where applicable
Occupational therapy
Physiotherapy
Speech & Language TherapyFluids/Diet modified? YES/NO – include details where applicable
NursingBP/mood/ anxiety
Has the patient actively engaged in therapy on the ward? YES/NO
How long are they currently able to engage in therapy for?
6 week goals for ESD
OT
PT
SLT
Function on discharge
Mobility
PADLS
DADLS / Communication
Cognition
Vision
Lone working risks and Safety issues
Environmental issues
Pets
History of:
Alcohol/Drug misuse
Mental Health issues
Aggression/ hostility  / Please give further details:
Is the home environment suitable for rehabilitation? YES/NO
Completed by:
Name: / Signature:
Designation: / Date: / Tel:

Referral process for ESD

  • Complete referral form & fax/ email to ESD. If emailing it must be sent from an nhs.net account
  • Complete & fax referral to ACHT if required
  • Phone ESD to discuss acceptance by ESD
  • Phone ESD when the patient is being discharged

NB. Patients have not been accepted by ESD until this process is complete.
T: 01494 425616 F: 01494 425369 E:

Version 5.1