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Referral Form

S2R

Kirklees

S2R provides services to Kirklees residents, 18+ experiencing mental health problems Name………………………………………………………….………………..DOB …../…../………… Address…………………………………………………………………………………………………….. . Post Code…………………….…… Ethnicity………………………. Male Female Telephone………………..……….. Mobile…………………….…… Referrer……………………………………………………… Telephone……………………………… In order for us to effectively support people moving towards recovery, we request referrers to provide details of the care plan. (please attach copy)

CPN / contact for care plan………………………………………..Consultant…………………………. GP…………………………………….Practice………………………………Tel: .………………………. Mental health details / reason for

referral………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Is attendance part of the Care Plan? Yes No CPA: Standard

Enhanced

Not on CPA

section 117:

Yes

No

Are you aware of anything which may suggest any risk to the individual or to others? Yes No If YES please give details ………………………………………………………………………………… ………………………………………………………………………………………………………………… n.b. We are unable to offer a service to people with high level of risk

Any other relevant information e.g.: diabetes, angina ………………………………………………… ……………………………………………………………………………………………………………… What services do you feel would be most useful at this time? (please circle) Self Help W orkshops

Relaxation

Social Confidence

Employment / Training Advice

Other (please detail) ………………………………………………………………………………………… ………………………………………………………………………………………………………………… Please tell us if you require feedback for this referral e.g. if attended, frequency of attendance ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Signed (referrer) ……………………………………………… Date ………/………./………… I would like to visit and find out more. (You are welcome to come with your CPN, or with a friend. If there is no one you can ask, please tell us and we will try to help). Signed ………………………………………………….. Date…………………………..

Please send Referrals to: S2R 1 st Floor, Revenue Chambers, St. Peter’s St, Huddersfield HD1 1DL Tel: 01484 539531 Fax: 01484 451710 or through the NHS internal mail system to: S2R c/o Princess Royal, Huddersfield


http://www.kirklees.nhs.uk/fileadmin/documents/your_health/Self_Care/Self_care_for_web/GPreferralv2s