This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
With this referral there is a possibility that information will be shared with Social Work Misuse Services and other agencies.
Is the client aware that information may be shared?
- Yes
- No
Other Agencies Involved
District nursing team involved:
- Yes
- No
Social Work involved:
- Yes
- No
Child protection involved:
- Yes
- No
Adult Supervision/Protection involved:
- Yes
- No
Additional Related Risk Assessment
Any current suicide risk:
- Yes
- No
If the patient has high suicide risk please give further details and actions taken: [Text]
Any history of aggression or violence or any risk to visiting staff:
- Yes
- No
If Yes, please provide details: [Text]
Any relevant physical disability or mental health problems:
- Yes
- No
Please detail or check that the details are presnet in the past medical history: [Text]
Please select all that apply:
- Responsible for children
- Domestic abuse
- Homeless or risk of
- Currently injecting
- Sharing injection equipment
- Self harm or injury
- Recent custodial sentence
- Pregnancy
- If pregnant please provide the due date: [Date]
Presenting Complaint
Main Presenting Complaint:
- Alcohol
- Drugs
- Alcohol and drugs
- Other
If alcohol referral please detail type, amount, how often, how long and anu features of dependency: [Text]
FAST score if known: [Text]
For drugs referral please detail substance, amount, how often and how long: [Text]
Current medication related to addiction. Please detail if not shown in medication record: [Text]
Date of Onset: [Date]
Priority:
- Routine
- Urgent
The service would consider pregnancy, sole carer of children and adults under Adult Support and Protection Act to be urgent.
If you consider the case to be ‘Urgent’ please give details: [Text]