North Kirklees Learning Disabilities Referral form To avoid delay in processing, please ensure that this form is completed fully. If you require assistance with this, please contact the duty officer between 1pm5pm.
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First Name
Title
(Also known as)
Surname
Date of Birth: _____/_____/________
M / F
Ethnic Origin: Please use categories on card
Address:
Religion: Please use categories on card
Post Code:
Tel No:
What is this person’s preferred language?
Does this person require help with communication? (e.g. interpreter/signer)
(Please specify)
Is the Carer disabled or suffering from an illness? Y / N Is the Main Carer over 70yrs? Y / N Is the Main Carer supportive of this referral? Y / N Is the client aware of this referral? Y / N Date of Referral: _____/_____/____ Person making the referral:
Agency:
Address:
How was the referral made? Telephone / In Person / Post / Internal Other_____________________________
Post Code:
Tel No: Aware of this referral?
GP: Contact details: Primary Carer:
Situation:
Contact details: Original referrer to the CLDT (if different to above)? Contact details: Next of Kin:
Relationship to client:
Contact details: Previous and Current Schools (If applicable)
What is the reason for this referral?
Pen Picture and background to referral (please include information on the client’s social situation, living arrangements, relevant history, disability and any health issues):
Current Risks (if any) and their Management:
Other professionals involved and services currently received:
Preliminary Action (if any):
Person completing this form: ____/____/_______ ALLOCATIONS: ____/____/________ Allocated to:___________________________________
Is this a New referral to the CLDT, or is it Internal: N / I
EPEX