Northern Region Gender Dysphoria Service (NRGDS) Referral Form

Patient details

Contact details

GP Details

Referrer’s details (if different to GP above)

Reasons for referral

Please include:

• Gender identity, their feelings about it and how these may have changed and developed over time.
• The impact on psychological wellbeing, social functioning, relationships and support networks.
• Their hopes and goals for the future – what do they want to happen?
• Whether they have attended this clinic in the past or have attended/are currently attending another gender clinic (including NHS and/or private clinics) – please include details of any past or current treatments.
• NB: If the person is currently receiving care or waiting for another NHS Gender Identity Service, please contact their current clinic to discuss options for transferring their care.

Substance use

Medical history

The referrer (if not the GP) may need to liaise with the GP for some of this information. Please include details of any surgery.

Please provide details of any past or current mental health history that you are aware of, including details of any other agencies that are/have been involved with the person. The referrer (if not the GP) may need to liaise with the GP for some of this information. NB NRGDS is not a general mental health service, if the person requires support with their mental health please refer to the relevant service.

Please give details of any current or historical suicidal or self-harm behaviour, any harm from others including domestic violence or exploitation and any convictions, cautions or licenses including any MAPPA and MARAC.

Medication Assessment

Include the name, dose and duration of each medication.

Include the name of medication, dose and details (e.g. how sourced, private prescription, duration of taking).

Gathering information

As part of our assessment and treatment process we gather information from other services and agencies.  

We gather information from you and other professionals involved in your care. An example of another professional that we would collect information from, is your GP. 

We only gather information, when it is necessary, to offer you assessment care and treatment. Gathering this information helps us to understand more about your history and current needs. It also helps us to understand if there are any risks to you or others. 

The information that we gather from you and other professionals will be kept in your Health Record (written and in an electronic record) to help us to provide you with the most appropriate care.

Sharing Information

We have a duty to keep information about you private and confidential.  There might be times when we have to share information about you without your permission. For example, to protect you or someone else from being hurt, or to prevent a crime. If this happened, we would share the smallest amount of information possible to protect people. 

The rules that we follow when sharing information are:

• Cumbria Northumberland Tyne and Wear (CNTW) Trust policies
• Common Law 
• Data Protection Act (1998)
• NHS Confidentiality Code of Practice

Keeping Information

When we write about your care and treatment, we keep that information in the electronic healthcare records system for CNTW. Correspondence we receive from you via email, will also be uploaded onto your Electronic Clinical Record.

Some people who use our service live in Cumbria, Northumberland or Tyne and Wear. If you live in one of those areas and use CNTW services, some of the information that we write, can be seen by those services.

When we meet with you we write two notes. 

1. One note can be seen by other CNTW services. This provides information about your mental health and wellbeing on that day. This is so that other people working with you can see basic information such as whether you might need support for your mental health.  It does not include details about your care or treatment in the gender dysphoria service. 
2. The second note, that we write when we meet with you, is kept in a separate part of the electronic healthcare records system. This note includes the details about the healthcare that we provide for you. Other people or services who provide healthcare for you cannot see those notes. 

If you do not live in the CNTW area then other services cannot see any of the notes that we write about you in our healthcare records system

In very limited circumstances, such as processing a complaint or ensuring that your record is accurate, other CNTW staff may open your record. These staff are bound by the same confidentiality guidelines.

Occasionally, information will be used for research, audit or training purposes, when all details that would identify you would be removed. This may happen after your care and treatment have finished. We may contact you after you have been discharged from the service to offer you the chance to take part in research, audit, service evaluation, or training.

Contacting people to share and gather information

We do not usually contact anyone to talk about your care apart from your GP. 
Sometimes it might be useful to speak to someone important who looks after your health and wellbeing. This might be a healthcare professional, like a doctor in another team, or someone who looks after you, like a support worker or social worker. 

We would not contact your family unless we had talked about this with you and you had agreed that it was something that you wanted us to do.

GP Records

If you live in the CNTW area, and some areas close by, staff working in this service will look at your electronic GP records to see treatment, consultations and investigations. 

We do this to help us to make decisions about safe care and treatment. We need to look at these records at various points in your care and treatment pathway. For example, if we asked your GP to take a blood test, we would look at your GP record to see the results.

Communicating with you about your care and treatment

As part of your assessment we will write letters about your care. We would like to give you a copy of these letters. We believe it could help you to understand and make choices about your own healthcare and treatment. It is your right to choose if you would like to receive a copy or not.

Please note you would be expected to attend a Diagnostic Assessment in-person even at short notice.

Please input your name, and the current date to sign the form