Request for support – Adult Mental Health Wellbeing Team.
(N.B. REQUESTS ARE NOT ALWAYS REVIEWED IMMEDIATELY UPON RECEIPT)
By Email to: [email protected] (Please make sure you password protect the document, and provide contact details for us to call and receive the password. By Post to: C328-9, County Hall, Market Road, Chelmsford, Essex, CM1 1QH
Please call the Referral Coordinator to discuss this referral, or if you have any questions. (033303 22958)
The role of the Adult Mental Health Wellbeing Team:
The Care Act places a duty on Local Authorities to provide Information, Advice and Guidance to adults with support needs, with the aim to prevent, reduce or delay the onset of care and support needs. MHWT will support adults who have mental health concerns where the adult will benefit from support, advice or information to meet a specific need, or where intervening now will prevent a crisis situation. This will include supporting people leaving long term mental health care provided by the Mental Health Trusts. The team will promote independence, self- reliance and recovery improving the quality of life and well- being of the individual, their families and carers. MHWT take a whole systems approach, and will, as part of the referral process, liaise with other services that the adult has or may have had contact with – please note, this is done only with the agreement of the adult. The adult should be aware of and consent to the referral. MHWT will not accept referrals where the adult is subject to ongoing Care Coordination by secondary mental health services. MHWT will aim to make contact with the adult within 5 days of the referral being received, and no later than 10 days.
SECTION 1 – Contact details – please review the consent to share information section at the bottom of this referral before completing this referral form. 1. a Name? DOB
1. b Has consent being given for this referral? Was this: Written Consent Verbal Consent
if 1b has not happened, please explain why?
Are there any risk or safety issues / hazards to be aware of? Yes No Unknown
If yes please specify (allergies, dangerous animals, poor mobile signal, substance misuse issues, etc):
Address
Contact telephone: Do we have permission to leave a message or a voicemail.
Email Address: NI Number and NHS Number:
Other Relevant Information:
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Please describe
Yes / No / NK Communication Needs / / Yes / No / NK Additional Mobility/Access Needs / / Yes / No / NK Cultural Needs / / Yes / No / NK Special Requirements / / Yes / No / NK Other / / Does the Adult share their home with other adults? If so, please record their details below:
Has the adult given If so please provide a First Name Surname Relationship to Adult permission to talk to this Contact number: person?
Does the Adult have any children? Does the adult share their home with other children or young people? If so, please record their details below: Are/were there any services involved with Does the adult have this child or young Parental Responsibility Name DoB Relationship to adult person? If so, please for this child or young detail who, and contact person? information below: Yes / No / NK / /
Yes / No / NK / /
Yes / No / NK / /
Yes / No / NK / /
Any other relevant information e.g. Interpreter/ Signer required; nature of disability:
Child/rens Main address Home Tel no: (including postcode) if different to the adult: Mobile no’s:
Current address if Home Tel no: different (e.g. staying with a relative): Mobile no’s:
SECTION 2 – REQUESTOR DETAILS (if not a self-referral):
V1.4 (March 2017) Page 2 Name: Agency:
Phone No: Address: (including postcode)
Professional role:
Email Address: (Please use a secure email address or follow your Information Governance Procedures) What is your current involvement with the adult?
This is confirmation of a request I made by telephone to the MHWT Shift Coordinator on (date) to (MHWT staff member):
Signature:______Date:______AGENCIES INVOLVED WITH THE ADULT: Agency Name Phone No.
Adult Mental Health
Family Solutions
Probation / Youth Offending Team
General Practitioner
Voluntary Sector
Housing Association/Supported Accommodation provider
Local Borough Housing Options Team. SECTION 3 – REASON FOR REQUEST What is going well for this adult and what resources/services are already in place?
What is going well? – what is making things go well?
What are your concerns for this adult? What existing support is in place for this adult that has been tested and proven to alleviate the concern;
Is there actual harm? – what action is causing the harm; Are there resources (eg family/friends/community) being accessed or services that are being provided to address the concern?
What is the factual information and evidence base specific to your concern; What are the views of the adult?
What are the future dangers for this adult should this concern not be addressed?
What are the complicating factors for this adult that makes the concern more difficult to deal with?
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Please read carefully, complete the restriction box if appropriate, then sign
I agree that personal information about me may be shared with or requested from other agencies and with other professionals, so that my need
I agree that personal information about me can be used for research to develop local and national practice (which will be suitably anonymised) and contribute to understanding needs across Essex. I agree that personal information about me may be shared with or requested from other professionals, so that I can be provided with services which i may benefit from I understand that I have the right to restrict what information may be shared and with whom, however information can be shared without con I understand that I may withdraw my consent to share information at any time – your key worker will arrange a discussion with you around the effects of this decision.
Information I do not want to be shared:
Full Name of the Adult Signature of the Adult Date:
This consent form
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