ADVICE AND REFERRAL CENTRE
(ARC)
REFERRAL FORM
Email Address - [email protected]
Phone Number - 0845 045 0123
Fax Number – 0845 045 0121
Referral
Category
Referral
Priority
4 Hour Response
Adult
(age 17-65)
24 Hour Response
Older People
(over 65)
Routine
Learning Disabilities Mental Health
Crisis?
4 Hour and 24 Hour referrals - please phone
the ARC first. (If 4 hour response is required,
GP must have seen patient within previous 24
hours)
GP DETAILS
REFERRER DETAILS (IF REFERRER IS NOT
GP)
GP Name
Title
Practice Address
Surname
First Name
Telephone Number
Email Address
Post Code
GP Practice Phone
Referring Profession/Organisation
GP Practice Fax
NOTE: If not GP referring, then GP must be
aware/agree with referral
PATIENT DETAILS
Title
Home Address
NHS Number
Surname
Ethnicity
First name
Nationality
Date of Birth
Religion
Tel Home
Employment
Tel Work
Post Code
First language
Tel Mobile
Email
Interpreter
required
Veteran
Patient’s preferred phone number for leaving voice messages
Gender
Marital status
Male
Unspecified
Yes/No
Yes/No
Female
Divorced/Partnership Dissolved
Not Disclosed
Married/Civil Partnership
Separated
Widowed/Surviving Partner
Single
DETAILS OF PRIMARY CARER (IF
APPROPRIATE)
DETAILS OF NEXT OF KIN (IF APPROPRIATE)
Name
Name
Address
Address
Contact
Number
Contact
Number
Relationship to Patient
Relationship to Patient
Consent given to involve Primary Carer
Consent given to involve Next of Kin
RISK ASSESSMENT
Overall Risk (as
perceived by referrer
at time of referral)
High
Moderate Low
Current
Yes
No
Past History
Yes
No
History of harm to others
History of self neglect
History of being serious exploited/vulnerability
History of harm/violence to others
Forensic history
Alcohol/substance misuse
If YES to any of the above please give details
Dependent children?
(If Yes please give names and
date of birth)
Yes
No
Details of any current
alcohol/substance abuse
Safeguarding Issues
Please give details
Any other information
DETAILS OF REFERRAL
Date of referral
Is patient aware of referral?
Yes
No
Date patient last seen
If referrer is NOT GP, is GP aware?
Yes
No
Please state any other professionals/NHS departments, or services, the patient is seeing?
Reason for Referral (include:)
Situation - what is the concern, who has been concerned, who has been aware
Background - when did this start, diagnosis, current medication, history, last contact with services
Assessment - clinical impression, concerns, underlying reason for the patient's condition
Clinical Presentation/Current State (including brief outline of presenting problems)
Current Medications
ATTACH GP SUMMARY of recent health problems, investigations and other information which
you think we should be aware of. Please include medical history, current medication, allergies and
sensitivities, blood tests and other relevant information/investigations
Name of Referrer………………………………………
Date …………………………………………………….. Time …………………………………..
OLDER PEOPLES MENTAL HEALTH
SUPPLEMENTARY INFORMATION
REFERRAL FOR
Confirmation of
diagnosis
Care Support
Treatment advice
Pharmacological
Psychological
Allocation option
Domiciliary
Clinic
INVESTIGATIONS
Memory
FBC, ESR, U&E, LFT, GCT, Corrected Ca, TFT, Glucose, (Vit B12,
Folate if indicated), ECG
Depression
FBC, U&E, TFT, Glucose (GGT if positive alcohol history)
On Lithium
Recent Lithium level
Referrer’s Name
Date
Eating Disorders Section
Eating Disorder Symptoms please complete the following information:
Body Mass Index (BMI)
kg/m²
BMI date
Weight:
kg
Height:
m
Scoff Questionnaire: Please ask patient and mark boxes as appropriate
Do you make yourself sick because you feel uncomfortably full
Yes
No
Do you worry you have lost Control over how much you eat?
Yes
No
Have you lost more than one stone in a three month period?
Yes
No
Do you believe yourself to be fat when others say you are thin?
Yes
No
Would you say that food dominates your life?
Yes
No
Symptom Checklist Please tick
Restricted food intake
Distorted body image
Restricted fluid intake
Significantly overweight
Binging
Other please state: e.g. pregnancy
Vomiting / Purging
Amenorrhoea
Below normal body weight
Self harm
Excessive exercise
Suicidal ideation (if present, please state
how the risk is currently managed)
Diuretic / Diet pills / Laxative abuse
History Of Rapid Weight Loss: Please Quantify (example: ½ kg/week, ½-1kg, 1kg / week)
Blood test results - tests should be taken within a week of referral – please include test date
Please fill in blood results for tests below, or attach blood results to this referral letter
Full blood count
Urea and electrolytes
Magnesium
Calcium profile
Phosphate
Glucose
Liver function test
Thyroid function test
ECG result
Blood pressure
4Hours/24 Hour Referral Section
 Situation (What is the concern, who has been concerned, who has been aware)
 Background (e.g. When did this start, diagnosis, current medications, previous history, last contact
with the services)
 Assessment (e.g. Clinical impressions, concerns, underlying reason for the patient's condition )
 Decision ( e.g. What is the plan, read back plan so caller is clear what is going to happen)
Will GP fax Patient Summary Across?
Yes
No