Referral form

Reason for the referral

service user Consent

Assessment

Please provide details of the following

Forensic History (If applicable)

Psychiatric History including previous hospitalisations

Risk assessment profile (latest HCR-20, DVRAG, COVR, START)

Current Care Plan and Support Needs:

Medication (list of medications and adherence)

Therapeutic Interventions therapies or interventions)

Support Needs (Daily living activities, social skills, vocational activities) – RCL will send daily living chart to referrer for initial assessment following receipt of initial referral

MDT Involvement:

List MDT involvement: Care co-ordinator, psychiatrist, psychologist, social worker, other professionsals

supporting documentation

Please email or provide any of the following documents relevant to the referral (where applicable):

Mental Health Act paperwork
DoLS (Deprivation of Liberty Safeguards) documentation
Court orders
Current care plans
Risk assessments

These documents help us gain a clear understanding of the individual’s needs and ensure appropriate care planning. If any documents are unavailable at the time of referral, please indicate when they can be provided.