Online Health Professional Referral Form
This form can be used by health professionals to refer patients who are:
- registered with a Southwark GP or GP at Hand, or
- Health and Social Care professionals (registered with any GP)
Patient Details
NHS Number:
Title:*
Please select
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First name:*
Last name:*
Date of Birth:*
Gender:*
Male
Female
Non-binary
Transgender Man
Transgender Woman
Other (Not Listed)
Pronouns:
Please Select A Value...
She/Her/Her
He/Him/His
They/Them/Their
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
Per/Per/Pers
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Address Line 1:*
Address Line 2:*
Town/City:*
County:*
Postcode:*
Telephone Number:*
Permission to contact by phone:*
Yes
No
Email:
Permission to send email:
Yes
No
Interpreter required:*
Yes
No
If yes, which language:
GP Details
Does the service user work for the NHS?:*
Yes
No
Does the service user work in Social Care?:*
Yes
No
GP Name:
GP Surgery:*
Demographic Information
Religious or Belief Affiliation:
Please select
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Pagan
Sikh
Zoroastrian
Other
None
Declines to Disclose
Patient Religion Unknown
Ethnicity:
Please select
White - A White British
White - B White Irish
White - C3 Other White
Mixed - D White and Black Caribbean
Mixed - E White and Black African
Mixed - F White and Asian
Mixed - GF Other mixed or mixed unspecified
Asian or Asian British - H Indian
Asian or Asian British - J Pakistani
Asian or Asian British - K Bangladeshi
Asian or Asian British - LK Other Asian or Asian unspecified
Black or Black British - M Caribbean
Black or Black British - N Other African or African unspecified
Black or Black British - PE Other Black or Black unspecified
Other Ethnic Groups - R Chinese
Other Ethnic Groups - SE Any other group
Unwilling to disclose - Z not stated
Sexuality:
Please select
Asexual
Gay Man
Lesbian
Heterosexual
Bisexual
Person is unsure
Unwilling to disclose
Not asked
Unsure or not known
Other
Unknown
Any additional information e.g. physical health conditions:
Referral Information - Risk
Are there any known issues of risk to 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 Southwark Assessment and Liaison Team or ask the service user to attend A&E.
Referral Information - Mental Health
Presenting problems (please give a description):*
Presenting problem - continued:
Is the service user currently involved with any other mental health teams?:*
Yes
No
If yes, please give details:
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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