Community Learning Disability Integrated Referral/record

Community Learning Disability Nurses facilitate healthcare, they are not direct

healthcareproviders. Therefore, always refer to your G.P. for primary health care needs

Please note highlighted fields must have the relevant information added in the text boxes or they will be returned

Personal Details

Surname

/

Address

Forename

Preferred

forename

DOB

NHS No.

/

Post Code

IW No.

/

Tel No.

Ethnicity

Male

/

Religion

Female

/

Name of Preferred contact

Has client given consent / awareness to this referral being made?

Relationship

Yes
No / Unable to consent /

Telephone

Is this referral
Urgent / Routine / GP name
Prac address
Referred by
Name
Position
Companyy / Practel
Address
Date of referral:
Tel
Principal carer/key worker / Care Manager
Name / Name
Tel / Tel
Address
Is this referral for a problem with swallowing / eating and drinking?
Yes / No
What is the difficulty?
If the referral is for eating and drinking difficulties, please send the form directly to Speech and Language Therapy, St Mary’s Hospital, Newport, Isle of Wight, PO30 5TG
WHICH HEALTH RELATED NEED(S) REQUIRE NURSE / PSYCHOLOGY /CONTINUING CARE/ SPEECH THERAPY / PHYSIOTHERAPY / PSYCHIATRIC ASSESSMENT AND INTERVENTION / OCCUPATIONAL THERAPY/HOSPITAL LIAISON NURSE (please highlight)
Please note we are a healthcare focused team and only take referrals when there is a health-related problem
Social care referrals need to go direct to the LA.

Reason for Referral

Desired Outcomes

Diagnosis
Additional information
Occupation/Day Time Activity
Name of company/ day centre / Telephone number / Day(s) attending
OFFICE USE ONLY
Awaiting Allocation Meeting
If urgent allocated to /
Date of next meeting

Is this inappropriate
Return to referrer

Please return the completed referral form to:

By Post: / CLDN Team Administrator, Arthur Webster Clinic, Landguard Manor Road, Shanklin, PO37 7HZ
By fax / 01983 867516
By Email: / please be aware of patient confidentiality if returning by email on an unsecured network.

K:\Referral forms\LD Referral Form Feb 14.docx