Worthing - Early Intervention in Psychosis Referral

Person Referred

Last Name: *

First Name: *

Also Known As:

Date of Birth: Day*

Date of Birth: Month*

Date of Birth: Year*

NHS Number: *

CIS Number:

Telephone Number:

Address: *

Current Accommodation
e.g. living with parents, renting, housing association etc: *

Gender: *

Male

Female

Transgender

Decline to state

Ethnicity: *

Religion/Belief: *

Marital/Civil Status: *

Language: *

Childcare Responsibilities - If yes, please provide details:

Vocational / Education Status: *

School

College

University

Masters

Doctorate

None

Are there other agencies involved?
Please provide the name of the service and any contact information

Do they consent to us contacting these agencies?

By Phone?

By Email?

Special Needs:

Service user aware of referral? *

Yes

No

Key Family or Friend contact

Name:

Address:

Telephone Number:

Relationship to client:

Is this person aware of referral?

Yes

No

Permission from client to contact?

Yes

No

GP

GP Name:

GP Practice: *

GP Practice Address:

GP Practice Telephone Number:

GP Email Address:

Is the GP aware of referral?

Yes

No

Referrer

Referrer's Name: *

Referrer's Telephone Number:

Referrer's Email address: *

Agency of Referrer: *

Please confirm your email address:

Reason for Referral

Reason for referral: *

Risk

Current risk issues identified by referrer: *

Past risk issues: *

Is there an up to date risk assessment? *

Yes

No

Mental Health

Current mental health problem/ diagnosis: *

Previous mental health history: *

Current Treatment

Current treatment: *

Drug and Alcohol Use

Current use: *

Past use: *

Please email us the following blood test results if these have been carried out in the last 3 months: FBC, U&E, LFT, TFT, prolactin, lipids, HBA1C, B12, folate and Vitamin D. Email to spnt.worthingeip@nhs.net.

Terms & Conditions

On receipt of the referral, we will consider whether or not the EIPS service may be the most appropriate service. If an appointment is offered this will be prioritised based on the presenting need.

The information you have provided will only be used for the purpose of receiving your referral and contacting you for further information about your referral if required. Your information will not be shared with anyone else without your consent. Information will be held as a part of the service user's record in line with the NHS Records Management Code of Practice.

I have read and agree with the above terms and conditions.*

Worthing - Early Intervention in Psychosis Service Referral (EIPS)