Leicestershire Partnership NHS Trust Adult Mental Health (Counties) Forensic Mental Health Services

FORENSIC MENTAL HEALTH SERVICES

REFERRAL FORM

CLIENT NAME:
PREVIOUS NAMES/ALIAS:
HOME ADDRESS:
POSTCODE:
CURRENT LOCATION:
POSTCODE:
TELEPHONE NO: / REFERRING AGENCY:
NAME:
ADDRESS:
TEL:
DOB: AGE: GENDER: M/F
MARITAL STATUS:
OCCUPATION:
MAIN LANGUAGE:
INTERPRETER REQ’D Y/N
RELIGION:
ETHNICITY:
NHS NO:
REGISTERED GP:
PRACTICE ADDRESS:
TEL NO: / RMO :
TEL:
CPN:
TEL:
SOCIAL WORKER:
TEL:
CARE FIRST/CISS NO:
OTHER WORKER INVOLVED:
TEL:
MHA SECTION:
DIAGNOSIS:
CPA LEVEL:
DATE OF LAST CPA:
PLEASE INCLUDE RECENT CPA REPORT
PLEASE INCLUDE COPY OF TRUST INITIAL RISK SCREENING TOOL AND ANY OTHER RISK ASSESSMENT THAT HAS BEEN UNDERTAKEN
DETAILS OF PROBATION ORDERS/LICENCE, ETC:
PLEASE INCLUDE OAYSIS REPORT if available
REASON FOR REFERRAL:
(PRESENTING PROBLEMS)
PSYCHIATRIC HISTORY:
Current medication:
Details of previous contact with mental health services (if known):
Details of inpatient admissions:
Is the client considered to have a personality disorder? Give details and criteria upon which the diagnosis was made?
Is there a history of self-harm? Is this an ongoing concern?
OFFENDING HISTORY
Details of previous convictions and sentences
Perception of current risk of further offences (please state upon what this is based)
Known mental state at time of offence
PERSONAL HISTORY
Give details of relevant circumstances or events
Is the client aware of this referral? What is their attitude/motivation to treatment?
Is there any previous history of non-compliance with treatment?
Does drug or alcohol use feature heavily in this person’s life? Is this related to their offending?
ANY OTHER INFORMATION
Please given any other information that could be useful to the FMHS in considering this referral i.e. health & safety considerations regarding risks to females, lone workers, etc; previous AWOL, nearest relative/main carer, etc.

PLEASE NOTE: This referral will be discussed at the earliest Referral’s Forum, occurring weekly. If the required documentation is not included with this referral form, it may be that the discussion/assessment is delayed.

It is our normal practice to provide feedback regarding the decision made by the team regarding referrals in writing

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