<p>Referral to South Wiltshire Community Mental Health Team Adults aged 16 to 65 (Page 1 of 3)</p><p>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)</p><p>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 </p><p>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</p><p>Please tick if GP Is the GP in agreement with this referral? Yes / No</p><p>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:</p><p>Duration of problem, current treatment, when started, previous treatments, were they successful or not, mental health history</p><p>Distress and dysfunction, emotional state, impact of problem on relationships, work, leisure etc, level of functioning </p><p>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</p><p>Other factors, housing, financial issues, alcohol or drugs, physical health issues</p><p>Ver 2.1 Referral to South Wiltshire Community Mental Health Team Adults aged 16 to 65 (Page 3 of 3)</p><p>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</p><p>Ver 2.1</p>