Online Health Professional Referral Form
This form can be used by health professionals to refer patients who are:
- registered with a Croydon GP or GP at Hand, or
- Health and Social care professionals (registered with any GP).
Patient Details
NHS Number:
Title:*
Please Select A Value...
Mr
Mrs
Miss
Mx
Ms
Dr
Rev
Prof
First name:*
Last name:*
Date of Birth:*
Have you ever been known by another Name or NHS number?
Yes
No
If you have answered yes, please provide details in the box:
Gender:*
Male
Female
Trans Male
Trans Female
Non-binary
Not known
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
GP Details
Does the service user work for the NHS?:*
Yes
No
Does the service user work in Social Care?:*
Yes
No
We will not be able to accept or process your referral if the service user is not registered with a Croydon GP. (We do accept referrals for Health and Social care workers who are not registered with a Croydon GP)
GP Name:
GP Surgery:*
Demographic Information
Is the service user seeking or have ever sought asylum in the UK? (This will not affect their treatment):*
Yes
No
Ethnicity:
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Asked but declined
Will the service user require an interpreter?:*
Yes
No
If yes, please specify language:
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
Cancel
