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Regal Optimal Referrer
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Regal Optimal Referrer
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Step
1
of 2
About you
Name
Job Title
*
Email Address
*
Date
Phone No:
*
Funding ICB
ICB contact
Referring organisation
Clinical Information to Support Referral
Please provide up to date clinical information to support assessment:
Reports selected below should be attached to an email and sent with this form.
3 months’ daily care notes
Yes
No
Recent tribunal reports especially any upcoming within 5 days
Yes
No
Up to date CPA reports (psychiatry, OT, psychology etc.)
Yes
No
HCR20
Yes
No
Recent psychiatric contact and assessments including; home treatment team
Yes
No
MHA documentation (copies of section paperwork)
Yes
No
Recent comprehensive risk assessment
Yes
No
AMHP report accompanying application (MHI)
Yes
No
Details of forensic assessments/history
Yes
No
Current medications chart
Yes
No
Current care plans
Yes
No
About the individual
Name of Service User
Date of Birth
*
NHS Number
Current diagnosis/es:
Current observation level:
Current placement details including full address, telephone number and ward name if applicable:
Current leave status:
Current service type:
Secure
PICU
Community Residential
Acute
Supported Living
Supported Living
High Support Inpatient Rehabilitation
Type of placement being sought (tick applicable):
Mental health rehabilitation
Complex trauma/personality disorder rehabilitation
Learning disabilities
Secure
PICU
Acute
Autism
Neuropsychiatric
Services
Details of MHA section (if applicable) and expiry date:
Has patient required seclusion in past 4 weeks?
Yes
Nio
Circumstances leading to current admission:
Has patient required seclusion in past 4 weeks? comment
Objectives to be achieved by onward placement:
Current RC name, contact number and email address:
Social Worker name, contact number and email address:
Care Coordinator name, phone number and contact email address:
Next of Kin details:
Name and address:
Phone
Relation to individual:
*
Contact email:
*
Has the individual given consent for the above person to be contacted?
Yes
No
Is next of kin also nearest relative?
Yes
No
Additional information:
Physical health conditions & supporting info where applicable:
Does the individual attend any regular hospital appointments?
Does the individual currently have any planned appointments?
Additional information; (Include any further relevant information & details of preferred service for consideration, if known)
Does the individual have specialist care plans? (eg. for diabetes or epilepsy)
Yes
No
If yes, please attach copies
Physical forensic applicable):
Risk Consideration:
Risk Factor (Historical)
Self-Harm
Suicide
Violence and aggression - self
Violence and aggression - peers/staff
Sexual Risk to Others
Arson
Vulnerability
Safeguarding
Drug Misuse
Alcohol Misuse
Absconding
Non-compliance with medication
Absconding on discharge
Further Information/Explanation on the selected factors
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