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Name of Referrer*
Address*
Referring Agency Name
Referrer Contact Number*
Referrer Email Address*
Date of Referral*
Client Name*
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
Name of GP*
Telephone Number*
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
Give names of any other agencies that are involved
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.