Referral to South Wiltshire Community Mental Health Team

Referral to South Wiltshire Community Mental Health Team Adults aged 16 to 65 (Page 1 of 3)

Urgency guide Emergency Urgent Routine Immediate and serious risk Risk of rapid deterioration over To be seen within 4 weeks next 3 days (as per commissioners target)

Patient Details: Surname Forenames Date of birth Previous surname NHS no. Title Sex M / F Address Marital Status Home tel. no. Work tel. no. Mobile no. Post Code Others in Carer/next of kin/ nominated contact household Name Address

Home tel. no. Ethnic group: W hite: Mixed: Asian or Asian Black or Black British: British White & Black Caribbean British: Caribbean Irish White & Black African Indian African Any other white White & Asian Pakistani Any other black background background Any other mixed background Bangladeshi Other Ethnic groups: Any other Asian Chinese Not stated background Any other ethnic group Referral Details: Referring GP Practice clinician /Department Designation Tel. no New referral / Re-referral (delete as appropriate) Date of referral Date last seen Date of consultation Dates unavailable Communication needs

Please tick if GP Is the GP in agreement with this referral? Yes / No

Ver 2.1 Referral to South Wiltshire Community Mental Health Team Adults aged 16 to 65 (Page 2 of 3) Mental health issues, signs and symptoms, behaviours, rating scales scores:

Duration of problem, current treatment, when started, previous treatments, were they successful or not, mental health history

Distress and dysfunction, emotional state, impact of problem on relationships, work, leisure etc, level of functioning

Danger, level of risk to self or others, actual, intent or thoughts, self neglect, other safeguarding issues, child protection, vulnerable adult, domestic abuse, contact with police

Other factors, housing, financial issues, alcohol or drugs, physical health issues

Ver 2.1 Referral to South Wiltshire Community Mental Health Team Adults aged 16 to 65 (Page 3 of 3)

Is the person being referred aware of the information sent regarding the initial appointment and in agreement with this referral? Yes / No Is the person able to come to the CMHT for an initial appointment? Yes/No Please fax to: 01722 820118 Or post to: South Wiltshire Community Mental Health Team, Heathwood, Fountain Way, Salisbury, SP2 7FD Tel: 01722 820116

Ver 2.1