ILCS Referral Form.doc - COMMON REFERRAL TOOL FOR TOWER HAMLETS MENTAL HEALTH SUPPORTING PEOPLE SERVICES To be completed by the Care

ILCS Referral Form.doc - COMMON REFERRAL TOOL FOR TOWER...

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COMMON REFERRAL TOOL FOR TOWER HAMLETS MENTAL HEALTH SUPPORTING PEOPLE SERVICES To be completed by the Care Coordinator/Referring Agent. Please also enclose the most recent CPA Documentation; (including Full Needs Assessment and Risk Assessment). PLEASE NOTE THAT WE WILL NOT PROCESS YOUR REFERRAL UNTIL WE RECEIVE THE ABOVE SUPPORTING DOCUMENTS. If available, also include recent medical reports and letters, OT reports and psychology reports. Forename: Surname: Date of Birth: Rio Number: Address: Post Code: National Insurance No.: Gender: Religion: Ethnicity: Nationality: Preferred Language: Interpreter Required: YES NO Reason for Referral: Please see our referral criteria, give brief details and confirm that this has been discussed with the client. (Please see inclusion and exclusion criteria in Appendix 1) Secondary Support Areas: Please indicate any other know support areas, which may require specialist support other than mental health (i.e. substance misuse, learning disabilities etc) Draft 1 August ‘09
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