You MUST Telephone the Appropriate Single Point of Access (SPA) Service to Discuss 1 Hour

Core Adult Secondary Mental Health Service GP Referral Form (MH1)

You MUST telephone the appropriate Single Point of Access (SPA) service to discuss 1 hour or 6 hour referrals prior to sending form to discuss the urgency.

For patients resident in Ealing, Hammersmith & Fulham, and Hounslow, refer to:
West London Mental Health Trust (WLMHT) Tel.: 0300 1234 244 e-mail:
For patients resident in another borough, please complete their specific referral form.
If in doubt please contact WLMHT / send and WLMHT SPA will forward to the correct service.
Please ensure that your patients telephone contact details are correct and that the correct SPA phone number has been given to them and explain that should their symptoms deteriorate they should call SPA immediately.

1. PATIENT DETAILS

/

1. REFERRER DETAILS

Forename / Date of Referral
Surname / Name of Referrer
DOB / Name of GP (if not referrer)
NHS No. / GP Surgery
Address / Address
Postcode / Postcode
Address CCG / GP CCG
Home phone / GP Telephone
Mobile / GP Practice e-mail / @nhs.net
E-mail / Bypass number for queries
Gender / E-mail for queries / @nhs.net
Ethnicity / Interpreter needed? / YES NO
Disabilities / Details: / Main Language spoken
Housebound? / YES NO

1. REFERRAL URGENCY STATUS – Please use risk profile below to assist in your decision. Further guidance at end of form

SPA will contact in
24 - 120 Hours
To be seen within
28 Days / SPA will contact in
24 - 72 Hours
To be seen within
7 Days / SPA will contact in
6 Hours
To be seen within 24 Hours / SPA will contact in
1 Hour
To be seen within
4 Hours
For 4 Hour or 6 Hour referrals, call the SPA to discuss the patient / SPA called? / YES NO
SPA may change the urgency status of the referral based on the information provided. GP to be informed.
Lower Risk / Potential Rating / Higher Risk / Brief details

1. Suicidality and self-harm behaviours

None or abstract ideation, no means or firm plan, no recent or prior attempts. / Expresses preference to die or self & shows intent. Has means and has immediate concrete plans.

1. Violent and aggressive behaviours

No significant recent history of violence or abusive behaviour. / Plans, with means, to cause harm, or through incapacity, unintentional neglect to others.

1. Safeguarding concerns (please ensure that you have raised an alert with social services if appropriate)

No known dependents or safeguarding risks. / Significant safeguarding risks, either as victim or towards others.

1. Previous mental health history

No history of mental health problems (NB: 1st symptoms later in life may be a high risk factor). No family history. / Has been under the care of mental health services, especially inpatient / crisis team in last 2 years.

1. WHICH SERVICE? Complete sections 5 – 7 & 12 for all, and the specific section as indicated by choice.

General Adult and
Older Adult
(not memory assessment) / First Episode Psychosis
(Ages 18 -65)
Complete box 8 / Perinatal (incl. pre-conception)
Complete box 9 / Eating Disorders
(Age 18+ )
Complete box 10
ADHD / ASD
(aged 18+)
Complete Box 11 / Primary Care Mental Health Service
Use PCMHS referral form / Memory Assessment Service
Use Memory referral form / Information sharing or a request regarding a patient already open to WLMHT services

1. REASONS FOR REFERRAL – please give explanation for priority status.

Please summarise the symptoms that the patient is experiencing, how this effecting their day to day living and what has already been trialled including any mental health medication, talking therapies and response.
<Event Details>
Has the patient consented to this referral? / Yes No
Has the patient been given the correct SPA contact no.? / Yes No

1. GOAL(S) OF REFERRAL – please consider both assessment and potential ongoing treatment.

Please include patient opinion and expectation of interventions within secondary care services.

1. SUMMARY OF RISK – please include suicide, self-harm and harm towards others.

Please elaborate on brief details above:
Details of current thoughts / ideation, ability to carry out plan and intention / intent to harm self or others.
Please elaborate on brief details above:
Details of past history of self harm, suicide attempts, harm to others.
Current/previous history of domestic abuse/violence? / Yes No
Any children (living with patient) under aged 18? / Yes No
Currently pregnant or up to 1 year post-partum? / Yes No

1. EARLY INTERVENTION IN PSYCHOSIS (EIS) ADDITIONAL INFORMATION (ages 18-65)

What indicates that this person is experiencing a first psychotic episode? (i.e. psychotic symptoms, changes in behaviours, social functioning difficulties, strange behaviours).
More than 7 days of symptoms? / Yes No
Any history of contact with CAMHS? / Yes No
Details:

1. PERINATAL MENTAL HEALTH (including pre-conception advice)

If patient is taking Sodium Valproate or Carbamazepine and pregnant or breastfeeding, please refer as 1 hour to Perinatal (via SPA) and notify GP/Prescriber immediately.
Attitude towards baby / unborn child:
Are there any identified risks towards baby / unborn child?
Is family known to Children & Family Social Services or has a Safeguarding referral been made?
If yes, please provide details of social worker/allocated early help worker:
Is there a family history of maternal mental illness or post-partum mental illness i.e. Bipolar Affective Disorder, Psychotic illness or Puerperal Psychosis?
Current mental state and attitude towards the pregnancy or new-born (How is the patient now)?
Other information (was pregnancy planned, unplanned, IVF, multiple pregnancy, support network):
Expected Delivery Date / DOB of child:
Antenatal Care Hospital (if known)
Name of Midwife or Health Visitor (if known)
Current community mental health team including private:
Obstetric History:
No. of previous pregnancies? / No. of live births?
No. of terminations? / No. of still births?
No. of neonatal deaths / No. of miscarriages?
Other children (living with or living elsewhere)
Name: / DoB / Living with? / Yes No
Name: / DoB / Living with? / Yes No
Name: / DoB / Living with? / Yes No
Please include any further children in ‘other information’ above.

1. WEST LONDON EATING DISORDER SERVICE (aged 18+ for Ealing and Hounslow residents only)

Test / Result (Last 6) / Date (Last 6)
Weight
Height
BMI
If BMI <16 and physical risk is present (eg. diabetes; abnormal bloods) please consider referral to Vincent Square the local tertiary service ( , 020 3315 2104).
IF BMI <15 REFER IMMEDIATELY TO VINCENT SQUARE EATING DISORDERS SERVICE BY CALLING 020 3315 2104.
Please indicate if there was a refusal to be weighed or sudden weight loss. Comment on restriction and frequency of vomiting, laxative use and bingeing (if applicable).

1. Attention deficit hyperactivity disorder (ADHD)

Please ensure you have done BP, BMI, ECG, FBC, U&E, creatinine, HbA1c, TFT and LFT.
Any history of contact with CAMHS? / Yes No
Details:

1. CURRENT MEDICATION INFORMATION / PHYSICAL HEALTH INFORMATION (auto populates if results available)

Acute Medication (in the last month):
<Medication(table)>
Repeat medications:
<Repeat Templates(table)>
Baseline observation tests: (Last 18 months)
Test / Result / Date
BP
ECG – please attach
Smoking status
Alcohol
HbA1c
Blood tests
Test / Result / Date
Full Blood Count
Haemoglobin concentration:
Total White Blood Count:
Platelet count:
Mean Cell Volume:
Neutrophil count:
Lymphocyte Count:
U&E’s
eGFR:
Serum Urea level:
Serum Creatinine level:
Serum Sodium level:
Serum Potassium level:
Urine Albumin Creatinine Ratio:
Serum lithium level
Erythrocyte sedimentation rate
Lipids
Serum Cholesterol level:
Serum HDL Cholesterol level:
Serum LDL Cholesterol level:
Serum Triglyceride level:
Total Cholesterol/HDL ratio:
Liver Function Tests
Serum alanine aminotransferase level (ALT):
Serum alkaline phosphatase level (ALP):
Serum Bilirubin level:
Gamma-glutamyl transferase level (GGT):
Serum Albumin level:
Bone Pofile
Serum Calcium level:
Serum inorganic phosphate level:
Thyroid Function Tests
Serum TSH level:
Serum T4 level:
Other Tests
Serum Glucose:
Serum lithium level
Vitamin B12 level
Serum Folate Level:
Serum Prolactin level
If you have feedback regarding the services (both positive and negative) please contact the SPA manager by email using:
WLMHT:

SPA will make contact within 1 – 5 days and if appropriate pass for a Face to face within 28 days (after SPA triage)
Age 18 or over, resident within and registered with a WLMHT borough CCG GP and aware that a referral is being made.
For all referrals the referring GP must check patients contact details and provide the patient with the SPA details and advise them to contact the SPA directly if their symptoms further deteriorate.
Moderate-severe anxiety / depression
Bipolar disorder
Schizophrenia
Enduring Personality Disorder
ADHD (not H&F).
Recurrent mental health episode (within the last year which required secondary care) / Have trailed 2 x antidepressants (of differing class) without adequate response and referral to primary care talking therapies has also been attempted.
Review of medications, diagnosis clarification and/or where presenting symptoms require father advice and support.
Where primary care interventions and voluntary/non-statutory options have been exhausted. / Fleeting active suicidal ideation but no current plan, intent or means and able to confirm that are able to maintain current safety.
Prognosis leading to progressive deterioration of the level of functioning without intervention from the Mental Health Services
Where consultant phone line / PCMHS advice, has confirmed that referral is suitable to secondary care services.
SPA will make contact within 1 – 3 days and if appropriate pass for a Face to face within 7 days (after SPA triage)
As for above referrals and any of the following:
Severe agitation accompanying anxiety or depression
Psychotic symptoms including delusions, hallucination and / or thought disorder / Presenting evidence of sufficient functional impairment that there is a risk to their own or others’ safety through direct harm or neglect.. / Active suicidal ideation or plans, with clear means, and/or history of such attempts but low intent and able to provide reassurance that will be able to keep self-safe while waiting for assessment
SPA will make contact within 6 hours and if appropriate pass for a Face to face within 24 hours
*contact SPA on 0300 1234 244 to discuss prior to sending*
As for above and any of the following:
1st Episode of psychosis and/or psychotic symptoms which include command hallucinations
Any other mental health crisis where an assessment is required under the Mental Health Act / Where serious and immediate safeguarding concerns (for children or vulnerable adults) appear related to mental health – have been reported to Social Services / Active suicidal ideation or plans, with intent and means to harm self or others within 24 hours
No other means to temporarily mitigate risk
SPA will make contact within 1 hour and if appropriate pass for a Face to face within 4 hours
*contact SPA on 0300 1234 244 to discuss prior to sending*
As for above and any of the following:
Severe mental health crisis which could require A&E attendance. / As an alternative to calling LAS to convey to A&E as an emergency presentation / Active suicidal ideas or plans, with intent and means to harm self or others immediately

Patient name: <Patient name> DOB: <Date of birth> NHS number: <NHS number> Template reviewed 07/03/2018