For Professionals

Professional Referral Form:

This form is for GPs and other professionals - if you wish to refer yourself, please use the Self Referral Form instead. Please note we can't accept referrals made by partners, family members or friends. By completing and submitting this form you are confirming that your client has agreed for their information to be stored on our confidential service database. This information is held securely and is not viewed by anyone outside of Impact on Teesside.

Referrer Details

Name: * Organisation Name: * Role: * Relationship to client: * Address of Organisation: * Contact Number: * Email: *

Client Details

Title: * Choose... Mr Mrs Ms Miss Dr Other Forename(s): * Surname: * Date of Birth: * Gender: * Choose... Female Male Non-binary Indeterminate Prefer not to say Please provide NHS Number (if known): Landline: Mobile: * Email: * Consent to leave messages?: * Address Line 1: * Address Line 2: Town/City: * County: Postcode: * Permission to Send Written Communication by Post?: * Disability: Choose... Deaf or serious hearing impairment Manual dexterity Learning disability Mobility and gross motor Perception of physical danger Personal, self care and continence Progressive Conditions and Physical Health (such as HV, cancer, MS, fits) Sight Speech Other Ethnicity: * Is English the clients first language?: * Is the client an NHS frontline staff working in a Teesside Hospital responding to COVID-19 cases? If the client is a student, please state the College/Sixth Form: Is the client a veteran? Service Number: Is the client or their partner pregnant? Please list the names and D.O.B of any children in the client’s care (up to 18 years old): Any safeguarding concerns? If yes, please detail any safeguarding concerns.

GP Details

GP Practice: * Choose... Chadwick Practice Havelock Grange Practice Drs Koh and Trory Gladstone House Surgery Hart Medical Practice McKenzie Group Practice Seaton Surgery The Headland Medical Practice West View Millennium Surgery Wynyard Road and Hartfields Medical Practice Alma Medical Practice Arrival Medical Practice The Dovecot Surgery Densham Surgery Dr Rasool Eaglescliffe Medical Practice Elm Tree Surgery Kingsway Medical Practice Marsh Medical Practice Melrose Surgery Norton Medical Practice Park Lane Surgery Queens Park Medical Practice Queenstree Practice Riverside Medical Practice Roseberry Practice Tennant Street Medical Practice Thornaby & Barwick Medical Group Woodbridge Medical Practice Woodlands Family Medical Centre Yarm Medical Centre Bluebell Medical Practice Borough Road and Nunthorpe Medical Group Cambridge Medical Group Coulby Medical Practice Crossfell Health Centre Discovery Practice Erimus Practice Prospect Surgery Ironopolis Medical Group (formerly The Endeavour Practice) Ironopolis Medical Group (formerly Martonside Surgery) Foundations 1 (formerly Fulcrum Medical) Foundations 2 (formerly Haven Medical Centre) Hirsel Medical Centre Kings Medical Practice Linthorpe Surgery Newland Medical Practice Park Surgery Parkway Medical Centre Thorntree Surgery The Village Medical Centre Westbourne Medical Centre Bentley Medical Practice Ravenscar Surgery The Green House Surgery Brotton Surgery Coatham Surgery Eston Surgery Normanby Medical Centre Hillside Practice Huntcliff Surgery Manor House Surgery Saltscar Surgery South Grange Medical Centre The Garth Surgery Springwood Surgery Woodside Surgery Zetland Medical Practice Registered GP: Current prescribed medication: Please provide details (inc. Dates) of any other previous/current service involvement (e.g. Talking therapies, secondary services, social services, drug/alcohol services, etc.)

Risk

Has the client...

Attempted suicide within the last 4 weeks? Active suicidal thoughts with plans to act on these? Active involvement with Crisis Team? Is a risk to others? If yes to any of the above please provide details of risk to self and to others (including history of self-harm or suicidality and previous convictions):

Reasons for Referral

Please provide details for referral (including any known mental health diagnoses): *

Next of Kin Details

Name: Telephone: Relationship to client: Address

Professional Contacts? (Where relevant / neccessary)

If 'Other' please specify: Name: Telephone: Email:

Please email any supporting documents including any assessments completed by Secondary Services (e.g. Access Teams or Crisis Teams), otherwise there is a possibility that this referral will be declined. A reference code will be provided on the next page.