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Referrer Information

Driving Assessment - Health Professional Referral form

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North East Drive Mobility – Driving and Passenger Assessment Service – CNTW095
Driving Assessments
Driving Assessment - Health Professional Referral form

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Personal details

Full name & title *Required

DOB *Required

Address *Required

Preferred Centre *Required

Newcastle upon Tyne

Carlisle

Teesside (Stockton-on-Tees)

Home phone *Required

Mobile *Required

Email *Required

Any known risks? (aggression, allergies etc)

Date of referral *Required

Interpreter required?

Yes

Reason for referral

What is the reason for the referral? *Required

What is the clients primary medical condition? *Required

Is the client currently driving? *Required

Client is currently driving

Client has been advised to stop driving while waiting for the assessment

Client would like an assessment to support returning to driving

Does your client drive a manual or automatic vehicle?

Does your client have current licence entitlement?

Yes

No

Unsure

Please note, clients without a licence can only be seen at our Newcastle Centre.

Medical history and current functioning

Relevant past medical history (please include any relevant cognitive assessment results)

Please list any current medication

How does the client’s medical condition affect them? (E.g. physical functioning, cognition etc.)

How does the client mobilise? Please detail any mobility aids you are aware of currently used (E.g. wheelchair, walking stick, walking frame)

How does the client currently transfer? (e.g. independently, with assistance or with aids)

Are there any issues you are aware of relating to the following?

Vision

Seizures

Recent surgery

Details

Has the DVLA been notified of the client’s medical condition?

Yes

No

Unsure

If your client has a notifiable condition and has not yet informed the DVLA please ask them to do so as soon as possible. (A list of notifiable medical conditions is available on the DVLA website)

Service access

Does the client have any of the following risk factors for failure to engage:

No insight into condition or potential impact on driving

Cognitive issues

Disengagement from other services

Difficulty getting to appointments

Lives alone

If so please consider supporting them to access the service.

Would your client be able to accept a last-minute appointment?

Yes

No

Has the client consented to this referral?

Yes

No

Referrer details

Name *Required

Role *Required

Address *Required

Tel number *Required

Email *Required

GP details

GP Name

GP Practice

Address

Tel number

Contact Details

Mobility Clinician, North East Drive Mobility, Walkergate Park, Benfield Road, Newcastle upon Tyne, NE6 4QD

Tel: 0191 2875090
Email: northeast.drivemobility@cntw.nhs.uk

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Driving Assessments - Patient self referral form

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St. Nicholas Hospital
Jubilee Road
Gosforth
Newcastle upon Tyne
NE3 3XT

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