Create Referral

Referrer Details

Name of Referrer *

Referrer Role *

Referrer Team *

Referrer Telephone Number *

Referrer Email Address *

Confirm Referrer Email Address *

Details of individual being referred

First name *

Last/family name *

Date of birth *

Adult/Under 18

Ethnicity

NHS number

Gender *

RAG Status *

Is the individual at imminent risk of placement breakdown and/or admission?

Yes: No:

If yes, please provide reason(s) why the person is at risk of placement breakdown and/or admission

Confirmed Diagnosis *

GP Name *

Address of registered GP practice

Postcode

Address of place of residence *

Postcode

Residence Type *

Current Care Provider (if applicable)

Care Provider Telephone

Care Provider Email Address

Confirm Care Provider Email Address

Current School (if applicable)

School Telephone

School Email Address

Confirm School Email Address

Looked After Child Status (LAC)

Responsibility

Responsible Local Authority *

Who is responsible for funding current placement? *

How is the package of care funded? *

Parent/Carer details

Parent/Carer name

Parent/Carer address

Postcode

Parent/carer Telephone Number

Parent/Carer Email Address

Confirm Parent/Carer Email Address

Current Care Team

Named Advocate

Named healthcare worker

Named Social Worker/Early Help Worker

Named education coordinator

Does the person have a current care plan that includes contingency planning with a current risk assessment in place?

Yes: No:

Date of last review of care plans and risk assessment

Has the person been offered a personal budget, personal health budget or integrated personal budget?

Yes: No:

Communication

Method of communication

First Language Spoken

Support Required

Brief History (last 12 months)

Please include information regarding previous in-patient admissions (physical or psychiatric), previous placements, forensic history (if applicable). Has the individual previously been “Sectioned”? If “Yes” please provide details of the location of where individual was detained and what Section was applied (e.g. S3/S37/49):

Date of community CETR if applicable

Date concerns started to escalate *

Date of Multi-Agency Meeting

Do you require a MAM organising as part of this referral? *

Yes: No:

Safeguarding

Please provide information about any safeguarding referrals or concerns

Additional Support

What additional support has already been put in place following identification of deterioration in health and well being?

Meeting Attendees (C(E)TR/MAM)

Please list the names and contact details of the individuals who you believe need to be invited to the meeting

Name	Role	Telephone	Email

Other information

Please include any other information that you think is important that has not been included elsewhere on the referral form

Create Referral to Dynamic Support Pathways (DSP)

Complete all relevant fields. Fields marked * are mandatory.

Referrer Details

Details of individual being referred

Responsibility

Parent/Carer details

Current Care Team

Communication

Brief History (last 12 months)

Overview of the current situation

What are the risk(s) – tick all that apply

Safeguarding

Additional Support

Meeting Attendees (C(E)TR/MAM)

Other information