Referral Form

Please only fill out this referral on behalf of clients who are registered with a GP or live in the Lewisham Borough.

Please advise the client that we will contact them directly once we have processed the form, and that their first appointment will be in normal working hours.

If you would like to discuss a potential referral please contact us on slm-tr.iaptlewisham@nhs.net

NHS Number:

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Non binary

Not specified

Address Line 1:*

Address Line 2:

Town/City:*

Postcode:*

Mobile Number:*

Permission to contact by phone?:*

Yes

No

Email

Permission To Send Email

Yes

No

GP Name:

GP Surgery:*

Does the client work for the NHS?:*

Yes

No

Does the client work in social care?:*

Yes

No

Religion:

Ethnicity:*

Sexuality:*

Is the client pregnant or has a child under the age of 1 year old:*

Yes

No

Any additional information e.g physical health concerns:

Are there any known issues of risk of harm to self:*

None

If risk is current please give details:

Is there risk to self and is there any know risk to others:*

Yes

No

If yes, please give additional details:

Presenting problem (please give a detailed description):*

Presenting problem continued:

Is the client currently engaging with any other mental health services?:*

Yes

No

If yes, please give details:

Does the client require an interpreter?:*

Yes

No

If yes, what language interpreter is required?:

Will the client have any other difficulties accessing our service?:*

Yes

No

If yes, please give more details:

Referrer Name:*

Job title of referrer:*

Referrer organisation:*

Referer contact details

Referrer Email:*

Referrer Telephone number:*

Please detail what support you have offered so far:*

Are you still working with the client?:*

Can you confirm client has consented to this referral and for their information to be shared:*

Yes

If you have any questions please contact us on slm-tr.iaptlewisham@slam.nhs.uk or 020 3228 1350

Please complete the captcha

Lewisham Professional Referral Form

Client Details

GP Details

Demographic Information

Referral Information- risk

Referral Information: Presenting Problem

Referral information: Access

Referrer details