Lambeth Early Intervention & Prevention Service (LEIPS) Referral form Demographic Details Client Name: NHS number:
GP Name: Address: GP Surgery:
Postcode: Referred by: As above Landline number: Occupation: Mobile number: Service name and address: Can a voicemail be left? Yes / No
Date of Birth: Gender: M / F Telephone number:
Ethnicity (please tick as appropriate) White Mixed Asian or Asian Black or Black Other Ethnic Groups British British British White and Black Indian Caribbean Chinese Caribbean Irish White and black Pakistani African Any other ethnic African group Any other White and Asian Bangladeshi Any other black Not Stated white background background Any other mixed Any other Asian background Background
Client Status as at (dd/mm/yy) ….../….../..…. Blood Pressure Height Weight BMI Smoker?
Yes/No
Has the client completed an NHS Health Check? Yes/No CVD Risk Score…………% Has the client completed a FAST/AUDIT C/AUDIT screen? Yes/No Score………………………. For GP and Practice Nurse use only: Please insert full medical extract here, alternatively complete the box below: Relevant Medical History Current Medication Services offered by LEIPS Alcohol Intervention: FAST/AUDIT screening, brief and extended interventions (up to six sessions).
Exercise on Referral: 8-12 week programme including twice weekly group exercise sessions and three self care skills sessions.
Expert Patient Programme: 6 weekly group sessions for individuals living with long-term conditions, disabilities or carers aiming to help clients learn new strategies to improve the management of their condition. Topics include the importance of taking medication, managing pain and dealing with difficult emotions.
Healthy Heart Healthy Weight: 12 week programme comprising weekly circuit-based group exercise sessions with healthy eating support and cooking demonstrations.
Health Trainers: Up to six one to one sessions to support an individual through lifestyle change such as eating healthily, increasing physical activity and reducing stress
Stop Smoking Service: Minimum 4 week structured intervention, including longer term specialist support for pregnant women, new mums and complex cases
Reason for referral
Referrals to exercise 1. If the client has a long term condition, have they been stable for at least 6 months? Yes No 2. If the client has diabetes, have they completed the DESMOND course? Yes No 3. Is the client able to walk independently (without human assistance)? Yes No For GP use only: Is this client safe to exercise at moderate intensity? Yes No If the answer to any of the above questions is ‘no’ the client is not likely to be suitable for exercise sessions and will be offered an alternative service. 4. Is the client currently undergoing any medical investigations? Yes No If so, please specify……………………………………………………………………………………………. ……………………………………………………………………………………………………………………. Referrer and client consent The information on this form is an accurate representation of the client’s health status. The referral has been discussed with the client who has given their consent.
Signed: Date: Please send the completed referral form to Lambeth Early Intervention and Prevention Service Tel: 020 3049 5242 Wooden Spoon House Fax: 020 3049 5256 5 Dugard Way London SE11 4TH Email: [email protected]