http://www.kirklees.nhs.uk/fileadmin/documents/your_health/Self_Care/Self_care_for_web/S2R_referral_

S2R Support to Recovery

REFERRAL FORM 1

Promoting Positive Mental Health

Please read carefully the following notes as they are intended to help you decide if the referral is appropriate.

Criteria 1 S2R provides services to adults up to the age of 65 who live in Kirklees.

2

Persons referred should have a primary diagnosis of mental health needs.

3

The person’s individual needs should have been assessed as potentially benefiting from our services.

Notes S2R is the name for the organisation created by the merger in April 2008 of DASH and Concern for Mental Health (also known as Viewpoints.)

S2R does have an expectation that those individuals referred will have had their needs assessed, and where a referral to S2R is being considered that we are involved in the care planning process.

Please provide a copy of the most recent Care Plan and the most recent Risk Assessment.

S2R assumes that this referral form will be completed in co-operation with the person referred. Please indicate if this is not the case and why.

S2R has a confidentiality policy which includes individual’s access to records. (This normally includes the referral form).

The information in this form will be used by S2R for the purposes of service delivery, as stipulated under the CPA and monitoring of equal opportunities.

For Office use only Date Received: Allocation:

Accepted: Service:

Revenue Chambers, 1st Floor, St Peter’s Street, Huddersfield, HD1 1DL Tel : (01484) 539 531 Fax : (01484) 451 710 contact@s2r.org.uk

S2R Support to Recovery

REFERRAL FORM 2

Promoting Positive Mental Health Name of person referred:

Name of Referrer: Tel:

DOB:

Date of Referral:

Address:

Post Code: Ethnicity:

Gender: (M/F)

Phone:

Mobile:

CPA attached

CPA level

□ Yes □ No

Enhanced None

□

□

Standard S117

□

Risk Assessment attached

□

□ Yes □ No

Community Professionals involved GP: Care Co-ordinator: Tel:

Tel:

Surgery and Address:

CMHT Team:

Psychiatrist:

CPN/ Social Worker:

Tel:

Tel:

Team:

Team:

Other workers/Agencies involved:

Revenue Chambers, 1st Floor, St Peter’s Street, Huddersfield, HD1 1DL Tel : (01484) 539 531 Fax : (01484) 451 710 contact@s2r.org.uk

S2R Support to Recovery

REFERRAL FORM 3

Promoting Positive Mental Health Name of next of kin: Relationship: Address:

Phone:

When would the person referred prefer to attend (Please tick)

□ Weekdays

□ Evenings

□ Weekends

Support Needs Identified

□ Leisure and Relaxation

□ Healthy Life Style/Living

□ Coffee group

□ Employment / Training Advice

□ Volunteering and Work Training

□ Community links (i.e. using library)

□ IT and computer skills

□ Numeracy and literacy skills

□ Football/gym/sport

□ One to One (time limited sessions)

□ Allotment/Gardening

□ Self Help Workshops

□ Walking Group

□ Lunch Group

□ Social Confidence

□ Counselling (please note: there is usually a waiting list)

□ Other (please specify) _______________________________________

Diagnosis (Diagnosis and nature of mental health indicated as part of past and current risk status) Revenue Chambers, 1st Floor, St Peter’s Street, Huddersfield, HD1 1DL Tel : (01484) 539 531 Fax : (01484) 451 710 contact@s2r.org.uk

S2R Support to Recovery

REFERRAL FORM 4

Promoting Positive Mental Health

Relevant medical information

Risk □ Low □ Medium If medium or high please give more detail

□ High

Please complete if relevant Mental state/Cognitive ability Behaviour/Relationships with others Physical health Ability to use public transport Cultural/Religious needs

Signed Referrer......................................................

Date………………………

Signed by Referred…………………………………………….

Date………………………

Revenue Chambers, 1st Floor, St Peter’s Street, Huddersfield, HD1 1DL Tel : (01484) 539 531 Fax : (01484) 451 710 contact@s2r.org.uk