of 6
Southwark Community Learning Disabilities Team
Referral for CLDT Services
Welcome to Southwark Community Learning Disabilities Team.
Please get someone you trust to help you to fill in this form.
Please fill in as much as you can.
If you don’t want to fill in the form please ring 020 8693 3839 (Health Team) or
020 7525 2032 (Social Work Team)
1. About you
What is your name?
What is your address?
What is your phone
number?
Date of Birth (D.O.B)?
Do you live with anyone?
Who should we talk to if
we need more information?
LDIP 026: Southwark CLDT Referral Form V3.03
Page 2 of 6
What is your GP’s name,
address
and telephone number?
Is there a Hospital Consultant
that you see regularly?
What is his specialty?
Have you received any
Learning Disabilities services
before?
What school did you go to?
2. The Help that you need
What type of help do you
need and why?
LDIP 026: Southwark CLDT Referral Form V3.03
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Is your referral to do with:
Help with sight problems
Yes
No
Help with hearing problems
Yes
No
Help with emotional and behavioural problems
Yes
No
Help to do as much as possible for yourself
Yes
No
Support to keep yourself mobile
Yes
No
Support to access leisure and sports facilities
Yes
No
Help with swallowing difficulties
Yes
No
Help with communication problems
Yes
No
Help from a Social Worker
Yes
No
Assessment for Day Services
Yes
No
Assessment for Residential Provision
Yes
No
Physical, financial, sexual or racial abuse
Yes
No
Help with Health
Yes
No
Help with Mental Health
Yes
No
Problems with where you are living
Yes
No
Some other need
Yes
No
LDIP 026: Southwark CLDT Referral Form V3.03
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Some more information about you that we need to collect.
Are you:
WHITE
X
Here
British
BLACK OR BLACK
BRITISH
Caribbean
Irish
African
Other White background
Other black background
MIXED
White and Black Caribbean
ASIAN OR ASIAN
BRITISH
Indian
White and Black African
Pakistani
White and Asian
Bangladeshi
Other mixed background
Any other Asian background
OTHER ETHNIC GROUPS
Chinese
Other ethnic group
I don’t understand this question
I don’t want to answer this question
I agree to Southwark Community
Learning Disabilities Team knowing
these things about me and sharing
them with others if necessary.
LDIP 026: Southwark CLDT Referral Form V3.03
Your Signature:
Date:
Or X
Here
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3. About the person that helped you with this form
The person that helped you with this form
should answer these questions.
(If you are a parent or unpaid carer, please also fill in
the Carer Form)
Your name (Person helping to complete
the form)
Your address
Your telephone number
How do you know the person?
I have explained this referral to the
applicant and the person was/ was not
able to give an informed consent:
Was able to give
informed consent
Was not able to
give informed
consent
Was not
present
Please send the completed form to:
CLDT - Health Team, 121 Townley Road, East Dulwich, London, SE22 8SW
Telephone: 020 8693 3839, Fax 020 7771 3635
Opening Hours: Monday – Friday 9am – 5pm
or CLDT - Social Work Team, 151 Walworth Road, London SE17 1RY
Telephone: 020 7525 2032, Fax: 020 7525 2317, e-mail:
[email protected]
Opening Hours: Monday – Friday 9am – 5pm
Telephone Number for Out-of Hours Emergencies: 020 7525 5000
You should receive an acknowledgement of your Referral Form within 3-4 days.
This will be by mail, or e-mail if you submitted the form by e-mail.
The symbols in this document are copyright of the commercial owners. They may not be copied or used in any
other format without the written permission from the owner. The graphic files produced by these symbol images
may not be used in any way other than to enable the viewing of this specific document
They are from:
The CHANGE Picture Bank.
Telephone: 0113 243 0202
http://www.changepeople.co.uk
LDIP 026: Southwark CLDT Referral Form V3.03
Widgit Software
Telephone: 01223 425 558
http://www.widgit.co.uk
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4.
For CLDT Use ONLY
Care First/Reference Number:
NHS Number:
CLDT Group receiving Referral :
CLDT - Social Work Team
CLDT - Psychology Team
CLDT - Health Team
Action Taken
No further action
Advised to seek other services Specify
Referral passed to other agency/team specify (eg welfare, housing, Benefits Agency)
Proceed with Specialist Assessments
Information given
Proceed with CLDT Overview Assessment
Further details/
information sought
CLDT Team Members’ Signatures
Name and address
Of CLDT Team Member
Signature
Date
Checked and approved by team leader (if appropriate)
Name & Signature
Date
Additional Information
Preferred Language
Religion
Unknown
Jewish
Sikh
None
LB Southwark Tenant
Is the person
An Owner Occupier
Does the person require any of the following:
Signer
Yes
Particular Arrangements
for Access
Interpreter
LDIP 026: Southwark CLDT Referral Form V3.03
Church of England
Muslim
Other - Specify
Roman Catholic
Hindu
Housing Association Tenant
Private tenant Other Specify
Braille/ Tape/
Yes
If Yes specify
Large Print
Yes
Advocate Yes