CONFIDENTIAL REFERRAL FOR
For the attention of the Team Secretary
Ashford & Shepway Community Learning Disability Team
Eversley House
19 Horn Street
Seabrook, Hythe, Kent
CT21 5SB
Tel: 03000 410501
Fax: 01303 717002
OFFICE USE ONLY

Date received

/ /
Screening
(clinician & date)
/ Date accepted at referral meeting / Allocated profession
External referral (please complete ALL sections of the form)
Internal referral (from member of the same community learning disabilities team). IF the client has a current accessible and up to date health file you do not need to give details of the main supporting services (page 2)

Mental Capacity

Does the person have a learning disability? yes no uncertain
Does the person have capacity to agree to this referral?
yes – in which case have they agreed to the referral yes no
no – please give the name of the person agreeing the referral is in their best interests: ______

Details of the person being referred

Surname / Date of Birth
First Name(s) / NHS number
Address / Swift ID
Gender
Marital status
Ethnicity
Postcode / Telephone
Details of the Referral
Referrer By / Organisation (if appl.)
Address / Contact telephone
Relationship to person
Reason for referral – please think in terms of what may be achieved for the person and attach additional information if required

Please also complete second page ../..

Main Supporting Services
Registered GP / Care Manager (if appl.)
Practice Name / CM team name
Address / Address
Telephone / Telephone
Main Carer (name/organisation) / Next of kin (name and relationship to person)
Address (if different from person being referred) / NOK address (if different from person being referred)
Telephone / Telephone
Additional Referral Information Required
Has the person being referred been seen by anyone else from the Learning Disability Team in the last 2 years?
Preferred place to see person being referred – home, clinic, day service, work etc,. Is a translator required? If so which language?
Necessary information regarding any serious medical condition of which we should be aware of? (E.g. asthma, diabetes, epilepsy, allergies)
Are there any risks to those attending for an initial visit (e.g. challenging behaviour, environmental hazards e.g. pets)
Signature / Date
Please contact the team at the address on the reverse if you need help filling in this form
Please provide full information or the referral may be returned to you