Mental Health Intermediate Care Team (MH ICT) Referral Form

If you have any questions about your referral, please phone the MH ICT Admin Hub on 0800 073 2200.

Patient Details – PLEASE PRINT
Title: Mr / Mrs / Miss / Ms / other
Name:
Address:
Postcode:
Contact Tel No: Landline Can messages be left? YES / NO
Mobile Can messages be left? YES / NO
D.O.B: ____ / ____ / ______Can text message reminders of
appointments be sent? YES / NO
RIO Number (if appropriate):
GO/EGT No/NHS Number: E-mail address:
GP Details: - PLEASE PRINT
GP Surgery:
GP name:
Contact Number:
Is the client aware of this referral? Yes/No
Has confidentiality been discussed? Yes/No
I agree to my GP being copied into any letters sent to myself Yes/No
I agree to the Dept of Health being sent basic data for statistical use only Yes/No
Referrer Details – PLEASE PRINT
Name:
Team:
Contact Number:
Date of Referral:
I have assessed this patient as having no significant risk and therefore as suitable for working with the MH Intermediate Care Team. Yes / No
What type of help is the patient hoping to receive from the MH Intermediate Care Team?

Please tick box: Therapy Nursing
Please use the Let’s Talk Introducing the IAPT service Leaflet or the website to input these scores:
PHQ9 total score (low mood) GAD 7 Total Score (anxiety)
Presenting Problem
Previous Mental Health Interventions/Involvement/previous medication (including dates)
Current and Previous Risk Issues / self harm, others, violence or neglect (please note that we do not accept patients with significant risk issues)
Current relevant Medication, including start date
Other Services currently involved (please detail)
Any other relevant information that will help us to consider eligibility and address the presenting problems (eg: drug, alcohol, physical health)
Please tick box:
Veteran of the Armed Services

Perinatal or postnatal up to 1 year

Send referrals to: Mental Health Intermediate Care Team

Ambrose House, Meteor Court, Barnett Way, Barnwood, Gloucester, GL4 3GG

Email: 2gnft.

Fax: 01452 894418

Phone: 0800 073 2200

As at 18.05.2016