ADULT / OLDER ADULT MENTAL HEALTH REFERRAL (North East Essex)

ADULT / OLDER ADULT MENTAL HEALTH REFERRAL (North East Essex)

ADULT / OLDER ADULT MENTAL HEALTH REFERRAL (North East Essex)

Dear GPReferrer

With effect from 1stMay 2017 the CCG is changing its provider of the Mental Health Clinical Triage Service (CTS) for planned/elective mental health referrals. Thetriage service will now be provided by Mid & North Essex MIND based in Colchester. Please use this formto make referrals for mental health services for patients aged 17 and above with the following EXCEPTIONS:

  • Referrals for patients in CRISIS or with suspected FIRST EPISODE PSYCHOSIS– please callthe Access and Assessment Service (NEE)on0330 726 1800to discuss the referral (this will ensure that there are no delays in the processing of thereferral).

N.B.:The SELF REFERRALoption to the HealthIn Mind IAPT serviceis still availablefor appropriate clients

Please select which service will best meet your patient’s needs. As a guide, mild to moderate mental health conditions should be directed to the IAPT service, and moderate to severe mental health conditions (including cognitive impairment) should be directed to EPUT secondary mental health services. Please note that your referral will be triaged on receipt (by both IAPT and NEP) and will be redirected if appropriate

Section 1 – Patient Details

Patient Name / NHS Number / Gender
M/F / Date of referral
Patient Contact Address (inc. Post Code) / Patient Date of Birth
dd-mm-yy / Contact telephone
(completion of this presumes consent has been given to leave messages)
Home:
Mob:
Name of referring GP / Surgery Name / Practice code:
Current Medication / Physical health conditions e.g.Long Term Conditions / Special requirementse.g.
Interpreter/Language; Transport/accessibility:
Presenting need / treatment expectations
Please indicate which service will best meet your patient’s needs: IAPT EPUT
Current presenting symptoms:
Impact on individual and family;
Significant life events;
Substance issues;
Previous mental health diagnoses / treatment for mental health problems;
Comorbidities i.e. LD (mild) / Autistic Spectrum Conditions / ADHD:

Section 2

Please put a cross X in the cell(s) that are most relevant to the symptoms your patient is presenting with

Presenting need / MILD / MODERATE / SEVERE
NON-PSYCHOTIC /
COMMON / Low mood
Anxiety
Phobias
Obsessions / compulsions
Post-Traumatic Stress
Panic attacks
Health anxiety
PSYCHOTIC / Hearing voices
Visual hallucinations
Paranoia / delusional thoughts
Mania / hypomania
COGNITIVE
IMPAIRMENT
(See notes below) / Memory impairment (diagnostic assessment required)
Established dementia diagnosis (if not diagnosed by NEP please enclose clinic letter from service confirming diagnosis)

For all Cognitive Impairmentreferrals please include Next of Kin details, ECG (if clinically indicated) and the following blood screen result (undertaken no more than 6 months ago)

Result / Result
FBC / LFT
ESR / Glucose
B12 / TFT
Folate / Calcium
U&E
Tick if present: / Comments:
RISKS / Suicide
Self-harm
Aggression / violence
Neglect
Child-protection
Vulnerability
Drug / alcohol use

Please email this form (all parts) along with any other supplementary information to the CTS Team at:

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