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

Patient Details:

Surname / Forenames
Date of birth / Previous surname
NHS no. / Title / Sex / M / F
Address
Post Code / Marital Status
Home tel. no.
Work tel. no.
Mobile no.
Others in household / Carer/next of kin/ nominated contact
Name
Address
Home tel. no.
Ethnic group:
White:
British
Irish
Any other white background
Not stated / Mixed:
White & Black Caribbean
White & Black African
White & Asian
Any other mixed background / Asian or Asian British:
Indian
Pakistani
Bangladeshi
Any other Asian background / Black or Black British:
Caribbean
African
Any other black background
Other Ethnic groups:
Chinese
Any other ethnic group

Referral Details:

Referring clinician / GP Practice /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

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

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

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