PRIMARY CARE MENTAL HEALTH TEAM
PATIENT REFERRAL FORM
Guidance Notes: Please ensure you provide us with as much information as possible when completing this form. All
fields marked with an asterix (*) are mandatory. IN ADDITION TO COMPLETING THIS FORM WE REQUIRE
YOU TO ATTACH THE PATIENT SUMMARY (ENCOUNTER RECORD) WITH THIS REFERRAL OR CLEARLY
STATE THAT YOU WILL NOT BE SENDING THIS. Failure to provide this information may result in refusal to accept
the referral or delay the process in which the client will be accepted into our Service. Please use BLOCK capitals
when filling in this form.
*Date of referral:
*NHS No:
*Title:
*Surname
*First name
*D.O.B:
*Gender: MALE
FEMALE
*Address 1:
*Address 2:
*Address 3:
*Post Code:
*Home Tel:
*Mobile:
*Marital Status:
*Does client have children
under 18 years?
Yes:
No:
Unknown:
*Ethnicity
(Pls refer to ethnic coding sheet attached):
*Interpreter required?
Yes
No
If YES please state language:
*GP Name
*Referrer details if not GP
*GP Address details
*Name:
*Address details:
*GP Tel:
Current Medication(s) With dosage and frequency
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*Tel:
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Barnet Primary Care Mental Health Team
2nd Floor, Dennis Scott Unit, Edgware Community Hospital, Burnt Oak Broadway, Edgware, HA8 0AD
Duty No: 0208 951 2194
Fax: 0208 951 2149
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Presentation – Symptoms/duration
Risk Features:
Alcohol & illicit drugs – quantities used, frequency, duration of use, ever injected? Any withdrawal symptoms from
alcohol or any other drugs?
Treatment/Services already involved:
Barnet Primary Care Mental Health Team
2nd Floor, Dennis Scott Unit, Edgware Community Hospital, Burnt Oak Broadway, Edgware, HA8 0AD
Duty No: 0208 951 2194
Fax: 0208 951 2149
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History:
Previous diagnosis, Admissions, Any self-harm? Cautions & convictions
Influencing Factors: Housing, current mental state, drugs& alcohol use, forensic history
Living/Social Circumstances: accommodation – rented/owned, current employment, social support networks incl. Day centres,
clubs etc. Financial circumstances incl. Income/benefits and any debts, attending any courses etc.
Dependants:
Pls specify if dependants under 18 years, or under 22 in full time employment.
Any other problems: Health, Social
Barnet Primary Care Mental Health Team
2nd Floor, Dennis Scott Unit, Edgware Community Hospital, Burnt Oak Broadway, Edgware, HA8 0AD
Duty No: 0208 951 2194
Fax: 0208 951 2149
3
ETHNICITY CODING GUIDANCE
In accordance with the Trust’s policy on ethnic monitoring, we collect information about the ethnicity
of people who use all mental health services. The information collected is used to address any
inequalities and to ensure that the needs of ethnic groups are being met.
Information about ethnicity is held confidentially in accordance with the Data Protection Act. Whilst
we would encourage you to provide this information, the Client is not obliged to do so. If they do not
wish to provide this information please enter “Not stated/refused” on the referral form.
Please enter on the referral form the ethnic group with which the Client identifies:
Asian or Asian British – Bangladeshi
Asian or Asian British – British
Asian or Asian British – Caribbean Asian
Asian or Asian British – East African Asian
Asian or Asian British – Indian
Asian or Asian British – Kashmiri
Asian or Asian British – Mixed Asian
Asian or Asian British – Pakistani
Asian or Asian British – Punjabi
Asian or Asian British – Sinhalese
Asian or Asian British – Sri Lanka
Asian or Asian British – Tamil
Asian or Asian British – Any Other Background
Asian or Asian British – Other / Unspecified
Black or Black British – African
Black or Black British – Caribbean
Black or Black British – Somali
Black or British Black – British
Black or British Black – Mixed
Black or British Black – Nigerian
Black or British Black – Somali
Black or Black British – Any Other Background
Black or British Black – Other / Unspecified
Mixed – Asian and Chinese
Mixed – Black and Asian
Mixed – Black and Chinese
Mixed – Black and White
Mixed – Chinese and White
Mixed – White & Asian
Mixed – White & Black African
Mixed – White & Black Caribbean
Mixed – Any Other Background
Mixed – Other / Unspecified
Other Ethnic Groups – Chinese
Other Ethnic Groups – Filipino
Other Ethnic Groups – Japanese
Other Ethnic Groups – Malaysian
Other Ethnic Groups – Vietnamese
Other Ethnic Groups – Any Other Background
White – Albanian
White – All Republics of former USSR
White – Bosnian
White – British
White – Cornish
White – Cypriot (part not stated)
White – English
White – Greek
White – Greek Cypriot
White – Gypsy / Romany
White – Irish
White – Irish Traveller
White – Italian
White – Kosovan
White – Mixed White
White – Northern Irish
White – Other European
White – Other Republics of former Yugoslavia
White – Polish
White – Scottish
White – Serbian
White – Traveller
White – Turkish
White – Turkish Cypriot
White – Welsh
White – Any Other Background
White – Other / Unspecified
Any Other Group: Please state________________
Not Stated (I do not wish to give this information)
Barnet Primary Care Mental Health Team
2nd Floor, Dennis Scott Unit, Edgware Community Hospital, Burnt Oak Broadway, Edgware, HA8 0AD
Duty No: 0208 951 2194
Fax: 0208 951 2149
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