PROFESSIONAL SUPPORT – REFERRAL FORM
NOTE FOR REFERRER
Referrers please ensure that this form is fully completed, accompanied by a Form B and that the doctor you are referring e-mails the PSU office () to indicate their acceptance of both the referral and the ‘note for trainee’ information at the foot of thispage. Without these steps being followed the referral cannot be accepted.
It is essential that Forms A & B have been shared, fully discussed, & agreed with the trainee prior to submission of the referral.
Please note trainees will be able to access these forms online.
CONFIDENTIALITY
Please password-protectyour Form before sending it to the PSU office. Please send a separate email to with details of the password you have used.
NOTE FOR TRAINEE
By agreeing to this referral and the information contained within it you are accepting the following terms for the management of your case by the Professional Support Unit:
You have read and understood the “PSU Information for Trainees” and the “FAQs for Trainees” (available from the PSU website) and understand both the purpose and the intention of the referral.
You understand that a case manager will be allocated to you and as part of the process a case file (both paper and electronic) will be opened.
You understand that information within your PSU case file is confidential and will only be accessed by members of the PSU or named case workers. Where existing documents held by members of Deanery teams are added to your file the original will remain the property of the team in question.
You are aware that the PSU will seek your permission to share relevant information with individuals, on a need to know basis, to inform and support your ongoing training.
You accept that any information which could compromise your own or your patients’ safety cannot be kept confidential and will be shared at the discretion of the Associate Dean for Professional Development
By accepting all of the above you also agree to communicate with your case manager and others involved by email and that you will ensure that the email address supplied is up to date at all times and is one that you access regularly (see Gold Guide 7.90).
Please note you will be able to access these forms on Intrepid.
PROFESSIONAL SUPPORT – REFERRAL FORM
Name:Tel No / MF
E-mail address
Specialty:
Grade:
Trust:
Start date of current post / End date:
Meeting date
Referral date
Name of referrer
Referrer email
Trust HR Link
Educational Supervisor
Educational Supervisor email
Clinical tutor/DME
Programme Director
Programme Director email
Programme Manager
Nature of problem / Health / Capability / Conduct
Summary of main issues
Issues identified / Communication/Interpersonal / Language Skills / Clinical Skills
Careers / Health Concerns / Health - Ongoing condition
Conflict with colleagues / Cultural Factors / Exam Failure
Time/Workload Management / Professional Conduct including probity / Team Working
Time Management / Other (Please state):
What action has already been taken?
Risk Factors
For examples of risk assessment please refer to Appendix C of the PSU Framework – Click here for the framework / Degree of risk to doctor:low medium high
Degree of risk to patients:low medium high
Degree of risk to employer:low medium high
Degree of risk to Colleagues/team: low medium high
Action plan for trainee
Action plan for assessor
Virtual Support Group
Further Support Proposed / Communication SkillsSupport / Career Counselling
Exam Support / Dyslexia Assessment
Language Support / General Practice Support
Addressing Professionalism / Mental Health Assessment
NCASReferral / Time Management Support
Occupational Health Assessment / Psychotherapy Assessment
Other: / GMC Referral
Review date:
Trainee has agreed to referral and has seen the completed Form A and Form B / YesNo
Date of agreement