SOUTHWARK & LAMBETH MEMORY SERVICE (SLMS)

The Gatehouse, Ann Moss Way, London, SE16 2TH

Tel. No: 0203 228 0570; Fax No: 0203 228 0571

REFERRAL FORM FOR ASSESSMENT AND TREATMENT

PATIENT:

Surname: / First name: / Title:
Address: / Postcode:
Telephone no: / NHS number: / DoB:
Ethnicity: / Main spoken language: / Interpreter required?
Yes / No
Lives alone? / Lives with? / Sex / Marital status:
Yes / No / Male / Female

CARER / NEXT OF KIN CONTACT DETAILS:

Please give details of anyone who will need to remind / assist the patient to attend appointments

Name: / Relationship:
Address: / Tel no:
History of presenting memory complaint: (duration / onset / symptoms)
Degree of cognitive impairment: / MILD / MODERATE / SEVERE
Medical history:
Current medication:
Risk factors identified:
Please tell us the best way to assess this patient:
Is able to attend clinic (unfortunately we do not provide transport)
Would require a home visit
Date of referral: / Requesting GP name: / Practice name:
Patient aware of referral? / Practice address:
Yes / No
Carer aware of referral? / Practice phone no: / Practice fax no:
Yes / No

SOUTHWARK & LAMBETH MEMORY SERVICE

Assessment and Treatment

To avoid delay, the following must be included with the referral:

Dementia screen blood tests (MUST be recent, i.e. within 3 months of referral date)

FBC
Random glucose
TFTs
LFT incl. GGT, B12 & Folate
U&E
MSU / ESR
Ca²+
CRP
Lipids
Syphilis / HIV screen

Please also attach a recent ECG if your patient has had one in the last 6 months

Bloods enclosed with Referral? / Yes / No / To be done? / Yes / No
Physical examination carried out / Yes / No / Date:

In keeping with infection control requirements, please tell us if any of the following conditions relate to this patient:

C difficile
MRSA
diarrhoea / urinary catheterisation
TB
None are applicable

Before returning this form to Southwark & Lambeth Memory Service, please ensure your patient meets our referral criteria:

Referral criteria

ü  Working age adults and older adults

ü  Subjective memory problems

ü  Change in everyday function over period > 6 months

ü  Carer’s report of change in client

ü  No previous or definitive diagnosis of dementia

The clinic will not see any cases where urgent attention is needed

e.g.

Behavioural problem

Suicidal ideation

Psychotic behaviour

Crisis situation from carer’s perspective

These cases should be referred directly to older adults’ CMHTs or ELMS as indicated.

Please ensure that all sections of referral form are completed and attach any additional information to this form. Thank you for your co-operation.

Please send your referral to: / POST: Southwark & Lambeth Memory Service, The Gatehouse, Ann Moss Way, London SE16 2TH
FAX: 0203 228 0571

SLMS Referral template: Jan 2014