Lothian Stroke Clinical Neuropsychology Referral Form
For inpatient referrals please discuss with psychology at team meeting or by telephone or email. Please consider the issues
overleaf when referring to the service
Clinical Neuropsychology Stroke service 0131 539 9140 (ext 49140),
Email neuropsych.aah@nhslothian.scot.nhs.uk or to our secretary (Jacqueline.wood@nhslothian.scot.nhs.uk)
By post Clinical Neuropsychology Stroke Service, Clinical Psychology building, Astley Ainslie Hospital, Edinburgh EH9 2HL
Patient Name:
Dob:
CHI Number:
Referrer (Name & Profession)
Gender: Male/Female
Address:
Contact Number:
GP:
Tel:
Marital Status (patient):
Details of CVA
Date of onset:
Diagnosis: stroke TIA SAH other________
Side: left right both midline dk
Classification: LACS PACS POCS TACS dk
Details from CT Scan:
Tel:
Results of Mood Screening:
Results of Cognitive Screening:
Details of any Communication Difficulties:
Current Patient Goals
Hosp:
Consultant:
Ward/Base:
Reason for Referral (what are staff looking for from psychology?) – refer to guidance overleaf
When would be an appropriate time to discuss this referral? ___________________
Signature: ____________________________
Date: _________________
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Clinical Neuropsychology Referral Guidance
Please consider the following issues prior to contacting the Clinical Neuropsychology Service.

What are the presenting problems?
o Try to be specific e.g., if difficulties in behaviour describe it clearly and in specific terms if
possible:
Try to avoid broad terms such as “aggressive” or “attention seeking” as they can be interpreted
in different ways. Better to say “Mrs X cries out repeatedly asking for pain relief, usually in the
afternoons”

In what way are the presenting problems affecting rehabilitation or discharge?

Does the patient see mood/cognition/behaviour as problematic?

What would staff like the outcome to be?
o e.g., better knowledge on how to deal with the problem, patient to be less anxious, more
information about subtle cognitive problems, guidance on behaviour management

What would the patient like the outcome of psychological input to be?

What has already been tried to help the situation? How well has this worked?

Have you discussed the referral with the patient?
Last updated Created on 26/03/2015 9:45 AM
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