Leeds Personality Disorder Clinical Network , Unit 24, The Sugar Refinery, Sugar Mill Business Park,
Oakhurst Avenue, Leeds, LS11 7DF, Phone 0113 8557950, Fax 0113 8557953
Email:[email protected]
Leeds Personality Disorder Clinical Network Referral Form
Date of referral:
Service being referred for:
Network care co-ordination
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Journey
Please note, there is now a separate referral from for DBT Skills groups
If a self-referral is being made, support is available to help complete this form if required.
Please contact Nicola Binns on 0113 8557950 to arrange for this support to be provided.
Service user details:
Name:
Male
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Female
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Is there another way in which you would like to
describe your gender?
…………………………………………………….
Age:
Date of birth:
Address:
Postcode:
Contact number:
Is service user aware of referral?
Yes
Referrer details (if applicable):
Name:
Position:
Address:
Contact number:
How long have you worked together:
Is the NHS care co-ordinator aware of the
referral (if applicable):
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No
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NHS staff details (if applicable):
Care co-ordinator name:
Psychiatrist name:
Office base:
Contact number:
1
Other agencies/individuals involved (e.g. housing, probation, social services, voluntary
sector) Please list below:
Reason for referral (please consider):
Service user characteristics (e.g. current needs, difficulties, complexity and risk)
Staff / service concerns (e.g. why specialist support is needed, difficulties with engagement, staff or
service user feeling ‘stuck’ )
Summarised mental health history:
Any diagnosis and / or mental health difficulties:
Brief details of previous / current contact with mental health services (e.g. contact with community
mental health team, crisis, in-patient and psychological services):
Any current medication:
Dose:
Any substance misuse (e.g. alcohol misuse and / or illegal substances):
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June 2017
Summarised risk information: (please attach a recent risk assessment if available / LYPFT
staff can refer to a current (completed within 3 months) FACE assessment if available on
PARIS)
Vulnerability (eg being taken advantage of and / or being harmed by others, please include
any safeguarding adults concerns):
Past:
Current:
Self-harm/ suicide (eg cutting, misuse of medication / overdosing and eating difficulties):
Past:
Current:
Risk to others (eg violence or aggression, please include any safeguarding children
concerns):
Past:
Current:
Occupational activity
(please describe how time is spent and any difficulties relating to activities of daily living,
education, work and leisure):
Group work information
(please describe any reasons why a group should not be considered and / or any previous
experience of group work):
Please attach any relevant further information:
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June 2017
Non LYPFT referrers please also complete the following information:
NHS no:
Ethnic origin:
Language:
Any current benefits:
Employment status:
Civil (eg marital) status:
Religion:
Lives with other people? If so, who:
Housing own or rented:
Housing permanent or temporary:
GP name:
GP address & contact number:
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June 2017