TRIAGE REFERRAL FORM

Please email completed referrals to:
Bristol - awp.BMHTriage@nhs.net
North Somerset -  awp.nsompcl@nhs.net
South Gloucestershire - awp.referralsonlysglospcls@nhs.net

PLEASE NOTE: NO FAX REFERRALS WILL BE ACCEPTED BY THE TRIAGE SERVICE

Urgency of assessment

Please indicate the urgency of this referral, i.e. how quickly do you feel that the patient needs contact from the service.

This is based on your clinical judgement and risk assessment. However, following triage by a Mental Health professional the timeframe to assessment may be amended in line with the UK Triage Scale. You will be notified of referral outcome by letter or email, following triage.

We will attempt to make contact within 72 hours unless the assessment is urgent. Please ensure that the patient’s contact details are up to date and please make them aware that we will call from a withheld number.

EMERGENCY/4 HOUR REFERRALS

For emergency/4 hour referrals, and 72 hour referrals, please contact your local PCLS service using the numbers below before submitting the form.
	
BSW                                                                                                	BNSSG
Banes: 01225 371480                                                                	Bristol (Triage Team): 0117 919 5670
Swindon: 01793 835787                                                          	North Somerset: 01934 836406
Wiltshire: 01722 820372 (South)/01380 737840 (North)	South Gloucestershire: 0117 3787960	
Urgent/routine referrals:
	
 Within 4 hours

Emergency mental health response
Please complete and submit this referral form to PCLS and then the referring GP contact your local PCLS service using the numbers above.

 Within 72 hours

Please complete and submit this referral form to PCLS.
	 Within 4 weeks

Routine mental health response

Please complete and submit this referral form to PCLS.	
Is this patient known to AWP services or was discharged from services within the last 3 months?
Yes       No  	

Patient details [details pulled directly from your clinical system]
	Referrer details
	
Full Name:		Preferred name:		Date of referral: 

Gender:
		D.O.B: 		Referring GP: 
	     	
NHS No:
	 	Marital status:
	 	Registered GP practice:	Tyntesfield Medical Group	

Address:
		Registered GP address:

	Tower House Medical Centre
Stockway South
Nailsea
Bristol
North Somerset
BS48 2XX 	
		Referring GP telephone no:  	01275 465100 	
Home Tel No:	 	Mobile Tel No:	 	Ethnicity:		
Religion/Belief:	 	Main language:		Interpreter required?

Pregnancy and maternity	Is the patient pregnant? 

Yes      No       Not applicable        
	
Disability 
	Does the patient consider themselves to be disabled?  Yes      No     
A person has a disability if s/he has a physical or mental impairment which has a substantial and long-term adverse effect on that person's ability to carry out normal day-to-day activities.

  Physical/Mobility (e.g. difficulty walking, climbing stairs, lifting & carrying objects)
  Vision (e.g. due to blindness or partial sight)
  Hearing (e.g. due to deafness or partial hearing)
  Learning or concentrating or remembering 
  Social or behavioural (e.g. due to neuro diverse conditions such as Autism, Attention
        Deficit Disorder or Asperger’s Syndrome)
  Other impairment

Please expand, as necessary:       
	
Gender reassignment

	Has the patient gone through any part of a process, or do they intend to (including thoughts and actions) to bring their physical sex appearance, and/or gender role, more in line with their gender identity? 
This could include changing their name, appearance, the way they dress, taking hormones or having gender confirming surgery

    Yes           No

Male/female assessor preference

   Male         Female
	
Sexual Orientation	Which of the following best describes the patient’s sexual orientation?

    Heterosexual/straight                Bisexual                    Lesbian                   Gay

    Other
	
Carer Details
	Patient carer who is available for support

Patient Carers

Other Patient Contacts
	Is there anyone (family/friend/others) that is providing support/involved in the care of this individual?
	
	Name
	Telephone Number
	Relationship
	
	Patient Contacts
No patient contacts recorded. 
	Patient Contacts
No patient contacts recorded. 
	Patient Contacts
No patient contacts recorded. 

     

Consent:
	Has your patient consented to a referral to this Service?
Yes   No  

If the patient does not consent to a referral, or you have concerns regarding capacity please specify the reason below:
     

Reason for referral – Referrals may be rejected without this information	
Please provide a narrative of your concerns about this patient’s mental state to include why he/she requires secondary mental health services and what you require from our assessment. Please also indicate what interventions you have tried in primary care prior to making this referral e.g. talking therapies, social prescribing, medication:  

Please see end of form.

     

Risk to self and others 
Please ensure you answer all of the following for the safety of patient, staff and the public	

	Yes	No	Not known	
1.	Is this person expressing thoughts of suicide or self-harm?				
If the answer to the above question was yes, please provide details
     
	
2.	Has the person ever made a suicide or self-harm attempt?				
If the answer to the above question was yes, please provide details
     
	
3.	Is the person expressing thoughts or has previously engaged in episodes of violence/aggression?				
If the answer to the above question was yes, please provide details
     
	
4.	Is the home environment safe to visit?				
If the answer to the above question was yes, please provide details
     
	
5.	Is there concern about harm or exploitation from others e.g. domestic violence, sexual harassment or abuse, financial abuse?				
If the answer to the above question was yes, please provide details
     
	
6.	Are there any child protection/safeguarding issues? 				
If the answer to the above question was yes, please provide details
     
	
7.	Does the patient have any dependents/children/vulnerable adults/pets? 				
If the answer to the above question was yes, please provide details
     
	
8.	Is the person at risk of self-neglect, physically or emotionally?				
If the answer to the above question was yes, please provide details
     
	
9.	Is there concern about the person’s general current behaviour e.g. risk taking, sleep pattern, activities of daily living? 				
If the answer to the above question was yes, please provide details
     
	
10.	Is there a history of misusing drugs or alcohol?				
If the answer to the above question was yes, please provide details
     
	
11.	Is there a history of depression or serious mental illness, including any current episode?				
If the answer to the above question was yes, please provide details
     
	
12.	Does the person have a shotgun/firearm licence?				
If the answer to the above question was yes, please provide details
     

Patient Consultations [Please upload latest results directly from GP system]	
Please provide last few consultations, wherever possible
 	
Patient Problems [Please upload latest results directly from GP system]	

Current medication being prescribed at date of referral [Please upload latest results directly from GP system]	
	
Confirmed allergies at date of referral [Please upload latest results directly from GP system]	
	
Recent diagnostics [Please upload latest results directly from GP system]