Name
ADVICE AND REFERRAL CENTRE (ARC) REFERRAL FORM
Email Address: cpft.arc@nhs.net ● Phone Number: 0845 045 0123 ● Fax Number: 0845 045 0121
NOTE: It is important that you fully complete this referral form so that we can triage
effectively and quickly. Incomplete forms delay assessment and may be returned.
PATIENT DETAILS
Name
Gender: Male
Female
NHS Number:
Address:
Nationality:
Ethnicity:
Preferred Contact Tel. Number:
Date of Birth:
Interpreter required? Yes
No
If yes, what language?
REFERRAL PRIORITY
24 HOUR HOME
TREATMENT
5 WORKING DAY
URGENT ASSESSMENT
ROUTINE
SOVA
NOTE: For all 24 hour (including SOVA) and 5 working day urgent referrals please
telephone the ARC first.
ONLY tick the 24 hour Home Treatment box if you consider that the patient needs
inpatient admission or daily CRHT involvement. You must have seen the person in the
past 24 hours.
We aim to assess all routine referrals within 8 weeks, but will prioritise as appropriate.
Please indicate in your referral letter if you feel a routine referral needs to be
prioritised and we will do our best to accommodate this.
RISK ASSESSMENT
NOTE: This section MUST be completed with full supporting information supplied in
the referral letter. Please include details of any personal safety plan.
Overall risk, as perceived by referrer at the time of referral: High
History of harm to self
Current
Yes
Moderate
Low
Past History
Yes
History of harm to others
Yes
Yes
History of self neglect
Yes
Yes
History of being serious exploited / vulnerability
Yes
Yes
Forensic history
Alcohol / substance misuse
Yes
Yes
Yes
Yes
REFERRAL CATEGORY
Adult (age 17-65)
Older People (over 65)
Veteran
Perinatal
CPFT staff
IAPT
1
Name
REFERRAL DATE:
DATE PERSON LAST SEEN:
BY WHOM:
GP DETAILS
REFERRER DETAILS (IF NOT GP)
GP Name:
Referrer Name:
Referring Profession / Organisation:
Practice Address:
Address:
Telephone Number:
Telephone Number:
GP Practice Fax Number:
NOTE: I confirm I have notified GP of
referral:
Yes
No, reason why:
NOTE: Please indicate if the patient consents to CPFT accessing primary care
records. This will allow us to follow up any specific information we need for triage.
Has the patient consented to share their primary
Yes
care record as part of their treatment and care?
No, patient refused consent
I don’t know/ couldn’t ask
Does the patient consent to staff at CPFT involved
in their treatment and care to view their primary
care record?
Yes
No, patient refused consent
I don’t know/ couldn’t ask
Is the person aware of the referral?
Dependent children?
Other dependants?
CPFT clinician aware of the referral?
Yes
No, reason why:
Yes
No
If yes, please provide details in the
referral letter
Yes
No
If yes, please provide details in the
referral letter
If you have discussed the referral with
one of our clinicians please let us
know in the referral letter
DETAILS OF PRIMARY CARER (if appropriate)
Name:
Address:
Contact Number:
Relationship to person:
Consent given to involve primary carer?
Yes
No
2
Name
PLEASE TYPE YOUR REFERRAL LETTER ON PAGE 4, COVERING
THE POINTS BELOW.
1. Reason for referral (please specify if this a referral for social care Community Care
Act assessment, or if you have a specific team in mind e.g. CAMEO/Early
Intervention)
2. Situation (what is the concern, who has been concerned and who has been made
aware)
3. Medical and psychiatric history (when did this start, diagnosis, details of alcohol
and/or substance misuse, please include full medical history)
4. Family history (any members of the patient’s family suffered from and/or undergone
treatment for mental health problems)
5. Clinical presentation (please describe current mental state)
6. Any concerns regarding risk (to self or others), or current social situation (e.g.
accommodation, relationships, financial circumstances)
7. Treatment and response so far (Details of first line treatment that has been tried
before referral. If the person has a relapse or crisis plan, or an advance statement,
have the recommended steps been followed? Please see referral guidance at
http://www.cpft.nhs.uk/professionals/GPs-and-primary-care.htm Please include
details of any other professional service/NHS department providing treatment.
8. Current medication (please list all medication currently being prescribed)
9. Other relevant information
SUPPLEMENTARY INFORMATION REQUIRED
ALL REFERRALS
Relevant correspondence from previous services/specialist
Attached
Results of any relevant investigations
Attached
GP summary printout
Attached
OLDER PEOPLE’S MENTAL HEALTH: MEMORY ASSESSMENT
FBC, ESR, U&E, LFT, GCT, Corrected Ca, TFT, Glucose,
Vitamin B12, Folate
Attached
ADULT EATING DISORDERS
Adult eating disorders supplementary form
Completed form attached
3
Name
***Please type the referral letter here ***
4