Which Discipline Would You Like to Refer To

GREENWICH COMMUNITY LEARNING DISABILITY TEAM

Civic House, 20 Grand Depot Road, Woolwich, SE18 6SJ,

Tel: 0208 921 4860 / Fax: 0208 921 4888

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REFERRAL FORM

Please complete with client as far as possible

Which Discipline Would You Like To Refer To?
Internal Referral only – Has this case been discussed with the respective discipline/s?
Yes/No (please tick)
If yes, then with whom?
If no, then please explain why?
Client Information
Name: / Date of Referral:
Gender: / MaleFemale / Sexuality:
Date of birth: / Age:
Address:
Tel No.
Has this person been screened for eligibility for CLDT services?
Yes/No (please tick)
If yes please state date:
Eligible/Not eligible (please tick)
Office use only
Framework i check / RiO check / Paper file check
(including non-LD files)
Referrer Information
Referrer’s Name:
Relationship to client:
Address:
Tel No.
Is the client aware of referral? / Yes/No
Does this person need to be seen within 24 hours? / Yes/No
Who is important in this person’s life (family/paid carer etc)
Of these people who can/should be involved in the assessment?
Has the client given consent? / Yes/No
Have the family been made aware of this referral? / Yes/No
Is the Key Worker aware of this referral? / Yes/No
If any of these parties are not aware that a referral is being made, please detail the reason below:
Reasons for referral
Are you continuing to work with this person? / Yes/No
Would you be prepared/able to do joint work with profession to whom you are referring?Yes/No
What level of learning disability do you feel this person has?
How has this been established?
Why/how do you think the client would benefit from this service?
Please attach additional sheet/information if necessary
Any special communication/language needs/additional information that may be helpful
Any racial, cultural, religious or sexual considerations which have relevance to the referral
Please complete the following if the CLDT does not have this information
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/ British Asian / Indian / Pakistani
Bangladeshi / Any Other Asian Background
Black/Black British / Caribbean / African / Any Other Black background
Other Ethnic Categories / Chinese / Any Other Ethnic Category
Not Stated / Not Stated
GP
Name:
Address:
Tel No.
Professionals involved and services received:
Additional Items
Care Plan in Place? / Yes/No
Client Receiving Services? / Yes/No
Living Situation:
Are there any risk factors possible in visiting?
Form completed by

Revised: 01 December 2011