OP & C
OUT-PATIENT AND COMMUNITY REFERRAL
1 of 2
Referral for Adult and Older Persons Out-patient and Community Therapy Services
(NHS No:
PLEASE NOTE: This is not a wheelchair or equipment order form.
First Name
Surname
Occupation
Title
Sex
DOB
Age
Tel
)
Mobile
Address
Postcode:
(Lambeth resident:
Next of Kin
Relationship
Other Carer/Contact person
GP Name
/
No
Mobile
Tel
Mobile
)
Address
Tel
Postcode
Recent Admission to hospital? Yes/No
Ward
Yes
Tel
Date
Hospital
Consultant
Tel
Reason
Actual or Desired Discharge Date
Diagnosis
Date of onset :
Off work due to problem Y / N
: If yes how long
Reason for referral (please include pre-morbid baseline and functional changes)/ Goals
Current Medication – List or attach chart / printout if clearer
Relevant Medical History
Recent Input / Interventions (please attach relevant reports)
Current investigations- e.g. Xrays, MRI (attach reports)
Social Situation – details please
Other Agencies/ Contact Details
Lives alone Y / N
Warden
Home Care
District Nurse
MOW
CPN/ other specialist nurse
Day Centre
Social Worker
Other relevant details
F104
OUT-PATIENT AND COMMUNITY GROUP REFERAL
First Name
OP & C
Surname
2 of 2
Date of birth
Type of service required – please circle
Physiotherapy
Consultant Clinic - Stroke
Occupational Therapy
Tissue Viability Clinic
Speech & Language Therapy
Falls Service
If you wish to discuss the referral further please contact SPA on 020 3049 4004.
Have you informed the client of this referral?
Outpatients:
YES
/
NO
YES
/
Home visiting: YES
NO
/
NO
If only for Home Visiting please state the reason:
Are there any known risk factors to home visiting?
YES
/
NO
If yes, please comment:
Does the Client have Impaired
Communication
Impaired Vision
YES
NO
Interpreter Required
YES
NO
Language Spoken
Impaired Hearing
YES
NO
Transport required?
YES
NO
Wheelchair and able to transfer
independently
Stairs inside property?
Details
YES
YES
Name of referrer
Designation/ discipline
Signature
Location
YES
NO
Walks alone / with one
YES
NO
NO
Wheelchair and not able to transfer
YES
NO
NO
Stairs outside property?
Details
YES
NO
Date
Tel no
Please send all referrals to be processed to:
Single Point of Access (SPA)
Pulross Intermediate Care Centre
47a Pulross Road
Brixton
SW9 8AE
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SPA Tel: 020 3049 4004
Email: [email protected]
Please provide FULL information to aid prioritisation.
Please attach relevant reports,
Please note incomplete referrals will be returned
Referrers may be advised where another team/ service/ centre is appropriate
F104