Online Health Professional Referral Form
This form can be used by health professionals to refer patients who are:
- Registered with a Lambeth GP or
- Live in the borough of Lambeth
Please advise the patient 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 email LIAPTScreeningteam@slam.nhs.uk. This email address is for health professionals only and should not be given to members of the public.
Patient Details
NHS Number:
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Female (including transgender female)
Male (including transgender male)
Non-binary
Not specified
Address Line 1:*
Address Line 2:
Town/City:*
Postcode:*
Telephone Number:*
Permission to contact by phone:*
Yes
No
Email:
Permission to send email:
Yes
No
GP Details
GP Name:
GP Surgery:*
Does the service user work for the NHS?:*
Yes
No
Does the service user work in Social Care?:*
Yes
No
Demographic Information
Religious or Belief Affiliation:
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Parsi / Zoroastrian
Rastafarian
Any other religion
Not stated (I do not wish to state)
Ethnicity
Please Select A Value...
White - A White British
White - B White Irish
White - CA English
Mixed - D White and Black Caribbean
Mixed - E White and Black African
Mixed - F White and Asian
Mixed - GA Black and Asian
Asian or Asian British - H Indian
Asian or Asian British - J Pakistani
Asian or Asian British - K Bangladeshi
Asian or Asian British - LA Mixed Asian
Black or Black British - M Caribbean
Black or Black British - PP Algerian
Black or Black British - PB Mixed Black
Other Ethnic Groups - R Chinese
Other Ethnic Groups - SB Japanese
Unwilling to disclose - Z not stated
Sexuality
Please Select A Value...
Heterosexual
Gay Man
Lesbian/Gay Female
Bisexual
Pansexual
Asexual
Other
Unwilling to disclose
Undecided
Unknown
Any additional information e.g. physical health conditions:
Referral Information - Risk
Are there any known issues of risk of harm to self:*
None
Previous
Current
If risk is current, please give details:
We cannot monitor risk until the client is seen, so please monitor until then. If there is active risk please refer to SPA team or A&E.
Referral Information - Mental Health
Presenting problem (please give a detailed description):*
Presenting problem - continued:
Is the service user currently involved with any other mental health teams?:*
Yes
No
If yes, please give details:
Referral Information - Access
Will the service user have any difficulty in accessing our services?:*
Yes
No
If yes, please give details, e.g. mobility, language:
Referrer Details
Referrer Name:*
Job Title of Referrer:*
Referrer Organisation:*
Referrer Contact Details:*
Please detail what support you have offered so far:*
Are you still working with the service user?:*
Please complete the captcha
Submit
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