Referral Form

Patient Details

Please use this for patients aged 16 and above. If you are referring a patient aged 15 or under please send the referral to nmh-tr.ewh@nhs.net

For patients aged 16 and above, please complete the following fields. Even if the patient is already registered with us, it will help us to process the request more efficiently. Please note: following triage or assessment it may be necessary for us to refer the patient on to specialist mental health services.

NHS Number:

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Not specified

Not known

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Telephone Number:

Permission to leave a message:

Yes

No

By giving us this information we are assuming that the patient consents to being contacted in this way.

Mobile Number:

Permission to leave a message:

Yes

No

Permission to send SMS text reminders:

Yes

No

By giving us this information we are assuming that the patient consents to being contacted in this way.

Email Address:

Confirm Email Address:

By giving us this information we are assuming that the patient consents to being contacted in this way.

Do you need easy read?

Yes

No

Easy Read - Information that is easier to read by using simpler words and pictures to help people understand.

GP Name:

GP Surgery:*

Nationality:

Ethnicity:*

Is the patient able to communicate in English?:

Yes

No

Preferred Language?:

If appropriate, please specify the dialect?:

Does the patient require an interpreter?:

Yes

No

Sexuality:*

Is the patient an Ex-armed forces member?:

Is the patient pregnant or have a child under two year’s old?

Yes

No

Is the patient's partner pregnant or have a child under two year’s old?

Yes

No

Carer for someone with a physical or psychological difficulties?:

Yes

No

If yes, adult or child?:

Adult

Child under 18

Does patient have any long term medical conditions?:

If yes, please specify:

Does patient have a disability?:

Is the patient aware of the referral?:

Yes

No

If the patient is under 18 years old, is the parent with parental responsibility aware of the referral?

Yes

No

If the patient is under 18 years old, can we share information with the parent?

Yes

No

What is the main reason for making this referral?:

Risk indicators:

Other agencies involved:

Current and past medication:

Any additional information:

Referrer First Name:*

Referrer Last Name:*

Job title of referrer:*

Referrer Organisation:*

Email address of referrer:*

Confirm email address of referrer:*

Please complete the captcha

Self Referral Form

Patient Details

GP Details

Further Information