Referral Form: Recovery Navigator Mental Health Support ICE  
Please return the form to: secondstep.icereferrals@nhs.net
Date of Referral: 		
Patient details
NHS No: 

Name: 

Date of birth: 

Address: 

Telephone number: 

Email: 
		
Referrer name and contact details (email and telephone):		
GP name and Surgery:
		
Brief background and reason for referral
E.g., developing coping skills around depression and anxiety, building self-esteem, developing a wellbeing plan, linking with or advocacy to access mental health support, safety-planning around suicide or self-harm, etc.		
Current mental health issues:
E.g., anxiety, depression, thoughts of suicide or self-harm, etc. 		
Current physical health issues:
E.g. mobility, diabetes, sensory impairment		
Any current or relevant risks 
E.g., around suicide, self-harm or safety concerns if meeting client in person.  Please also include details of any triggers:		
Any other support including other services in place (current and past):
e.g. formal or informal carers, drug/alcohol support, housing support, social worker		
Is the patients first language English? 
If not, please state what their first language is and if a translation service is required. 		
Are there any access requirements (if known)? 
E.g., text before making initial contact, times of availability (between 9am-5pm), or face-to-face support required for patients hard of hearing		
Has the patient consented to this support? 
Have they been told that Second Step will be contacting them to provide some support? If not, why not
Do they know their contact details will be shared with the Recovery Navigator?
Consent must be sought prior to contact being made		

Additional information for referrers:
The Wellbeing & Recovery Service is a new mental health project supporting people with complex needs and who have moderate to serious mental health problems. It is a holistic, community-based service that can engage with patients pro-actively over the phone, internet, in the community or via home visits. This Recovery Navigator service operates within primary care in Inner City & East Bristol and is delivered by Second Step.
Referrals can be made by any healthcare professional working in primary care, for patients registered with one of the GP surgeries in Inner City & East Bristol (i.e. Inner City PCN, Fireclay & Old School PCN (FOSS) and Fishponds, Air Balloon & Beechwood PCN (FABB)). We also accept referrals through the Inner City & East Bristol Integrated & Personalised Care Team, of which our service a core member. We cannot accept self-referrals directly from patients.
This referral form is to provide essential information to advise the Second Step Recovery Navigators of the support needs of the patient and to highlight any risks or triggers (if known) that lone working staff need to be aware of when conducting home visits. It is helpful if a summary medical record can be attached along with this form.
Inclusion Criteria: 
This is a service supporting people with moderate/serious/complex mental health needs. We can support:-
-	People who are over 18 years old
-	People who are too complex for social prescribing/IAPT but are not meeting secondary care thresholds. 
-	‘Frequent attenders’ who require 1:1 support to address complex social issues
-	 People stepping down from secondary care.
Recovery Navigators can offer:
•	Short-term, individual sessions based on the client’s goals (normally 6-8 sessions).
•	A personalised approach tailored to the client’s needs
•	A holistic approach that encourages wellbeing, empowerment and resilience
•	Building a therapeutic relationship with the client, where they feel understood, accepted and supported
•	A wide range of psych-educational and psycho-social interventions based on self-help techniques from validated therapeutic models (e.g. motivational interviewing, solution-focused therapy, cognitive & behavioural therapy, dialectic behavioural therapy, compassion-focused therapy etc.)
•	Co-produced planning to promote safety, crisis management, harm-reduction, wellbeing and the recovery journey
•	Signposting, referral, co-ordination and collaboration with other service providers to develop a pathway for the client’s recovery journey

Recovery Navigators cannot offer:
•	Long-term or open-ended support
•	Support work (for example going to café's, shopping, cooking, cleaning, form-filling etc), although we may be able to signpost clients to these services, where they exist.
•	Ongoing care coordination
•	Formal counselling or talking therapy.
Recovery Navigators will not be able to support: 
-	Children under 18
-	Patients with dementia 
-	Patients in receipt of secondary care mental health services  
-	Learning disability if this is the primary reason for referral 
-	Significant dependency on drugs/alcohol that means they will not be able to engage in support.