Date of Referral

CHST Continuing Care Referral Form: Complete all sections KEY CONTACTS Name of referred person DoB

Contact details for referred person Address: Tel:

Next of kin details Name & address: Relationship: Tel:

PROFESSIONAL INVOLVEMENT GP Name & address: Tel:

District Nurse Name & address: Tel:

Social Worker Name & address: Tel:

Core Assessment Attached: We will not accept this form without an up-to-date community care assessment REFERRAL INFORMATION IMPORTANT: Please include all essential information: CHST will contact you to confirm that your referral has been accepted. Date of Referral: Continuing Care Checklist attached (We will not accept your referral without a checklist) Reason for referral: (Please summarise in the box)

Referrer’s contact details: Name: Address: Phone:

Role: Fax:

Organisation: Email: Send to CHST: E mail: [email protected] Fax: 020 3049 8820 Post: The Grove, Dulwich Community Hospital, East Dulwich Grove, SE22 8PT CHST Continuing Care Referral Form: Complete all sections Please indicate the patient’s ethnicity by ticking the corresponding box, referrals without this information will not be accepted.

Tick Ethnicity Tick Ethnicity Tick Ethnicity White - British White - Greek Asian or Asian British - East African Asian White - Irish White - Greek Cypriot Asian or Asian British - Sri Lanka

White - Any other background White - Turkish Asian or Asian British - Tamil

Mixed - White & Black White - Turkish Cypriot Asian or Asian British - Sinhalese Caribbean Mixed - White & Black African White - Italian Asian or Asian British - British

Mixed - White & Asian White - Irish Traveller Asian or Asian British - Caribbean Asian Mixed - Any other mixed White - Traveller Asian or Asian British - background Other/Unspecified Asian or Asian British - Indian White - Gipsy/Roma Black or Black British - Somali

Asian or Asian British - White - Kosovan Black or Black British - Mixed Pakistani Asian or Asian British - White - Polish Black or Black British - Nigerian Bangladeshi Asian or Asian British - Any White - All Republics of Black or Black British - British other background USSR Black or Black British - White - Albanian Black or Black British - Caribbean Other/Unspecified Black or Black British - White - Bosnian Other Ethnic Groups - Vietnamese African Black or Black British - Any White - Croation Other Ethnic Groups - Japanese other background Other Ethnic Groups - White - Serbian Other Ethnic Groups - Filipino Chinese Other Ethnic Groups - Any White - Other Republics of Other Ethnic Groups - Malaysian Other Group former Yugoslavia Not Known (Not Requested) White - Mixed White Any Other Group

Not Known (Unable to White - Other European Other Ethnic Groups - Arab Request) Not Stated (Client Refused) Mixed - Black and Asian Other Ethnic Groups - North African Not Stated (Client unable to Mixed - Black and Chinese Other Ethnic Groups - Other Middle Choose) East White - Northern Irish Mixed - Black and White Other Ethnic Groups - Israeli

White - Other/Unspecified Mixed - Chinese and White Other Ethnic Groups - Iranian

White - English Mixed - Asian and Chinese Other Ethnic Groups - Kurdish

White - Scottish Mixed - Other/Unspecified Other Ethnic Groups - Moroccan

White - Welsh Asian or Asian British - Mixed Other Ethnic Groups - Latin Asian American White - Cornish Asian or Asian British - Other Ethnic Groups - Punjabi South/Central American White - Cypriot (part not Asian or Asian British - Other Ethnic Groups - stated) Kashmiri Maur/SEyc/Mald/StHelen