CLDT USE ONLY:
Date referral received:
REFERRAL TO COMMUNITY LEARNING DISABILITY TEAM
Before completing this form, please read the enclosed guidance and ensure that the referral
meets the specified criteria. Please complete all sections of the referral form, giving as much
information as possible and attaching additional reports if appropriate. Thank you.
1. PERSON REFERRED
Name:
DOB:
Address:
CHI NO:
TEL NO:
2. CONTACT PERSON
Name:
TEL NO:
Relationship to client:
Address:
FAX NO:
3. REFERRAL DETAILS
Date of Referral:
Referred By:
Address:
Position:
TEL NO:
4. GENERAL PRACTITIONER (THIS SECTION MUST BE COMPLETED)
Name:
TEL NO:
Address:
5. BRIEF HISTORY AND REASON FOR REFERRAL (Service requested if inter-team)
Revised 8 August 07
6. TEAM PROFESSIONALS CURRENTLY INVOLVED
 Nursing
 Psychiatry
 Dietetics
 Occupational Therapy
 Physiotherapy
 Art Therapy
7. SOCIAL WORKER
Name:
Tel No:
Address:
Fax:
 Clinical Psychology
 Speech & Language Therapy
8. KEY WORKERS, DAY PLACEMENTS, OTHER SUPPORTS ETC
9. KNOWN RISK/PRIORITY FACTORS – IF YES TO ANY OF THESE, PLEASE GIVE DETAILS
RISK TO CLIENT
 Is there a risk of neglect, abuse or Vulnerable Adult issues?
 Are there any Child Protection issues?
 Is there a risk of self harm?
 Are there significant changes or events in the person’s health status eg choking, weight loss?
 Is the person’s current or residential placement at risk of breaking down?
 Are there significant changes in the person’s behaviour?
 Does the person have inadequate support networks?
 Are there any transition issues?
RISK TO STAFF
 Any history of physical aggression?
 Any history of verbal aggression?
 Any sexually inappropriate behaviour?
 Any environmental risks eg poorly lit entrance, animals etc?
10. Has client/carer consented to this referral?
YES / NO
11. Has a Carenap/e-Assess been completed?
(If available, please enclose Carenap)
YES / NO
12. Does client/carer have any communication
requirements to aid our initial contact?
If Yes, please specify:
13. Does client/carer have any environmental
requirements to aid our initial contact?
(ie visit at home/clinic/day placement)
If Yes, please specify:
14. Additional information attached
YES / NO
YES / NO
YES / NO
Revised 8 August 07