Referrer Details

Name of Referrer*

Address*

Referring Agency Name

Referrer Contact Number*

Referrer Email Address*

Date of Referral*

Client Details

Client Name*

Address*

Date of Birth*

Client Contact Number*

Disability
YesNo

Gender*
—Please choose an option—MaleFemaleTransInterPrefer not to say

Ethnicity*

Preferred Language*

Faith*

Sexual Orientation*
—Please choose an option—HeterosexualHomosexualBisexualAsexualPrefer not to say

NHS Number

Next of Kin

Relationship to Next of Kin

Contact Details of Next of Kin

GP Details

Name of GP*

Address*

Telephone Number*

Referral Details

Reason for Referral / Support Needs*
DepressionAnxietyBipolarPsychosisOther

If the reason is not listed, please enter it below

Support Level*
HighMediumLow

List any medication currently taken

List any risks (attach risk assessment if possible)*

Have accessed CAMH (if under 24)*
PreviouslyCurrentlyNot Applicable

Other Agencies

Give names of any other agencies that are involved

Data Protection

By providing the information in this referral, the client, referrer (and legal guardian if required) understand that the data may be shared with other agencies such as the NHS, Council and other partner organisation who may be involved in the delivery of care for the client or where an issue of safeguarding arises. Where this happens you will be informed.

Client Consent*
YesNo

Legal Guardian Consent (if under 18)?*
YesNo

Referrer Consent?*
YesNo

Date*

* denotes a required field.