Is this a Routine referral or Urgent referral? Required

Part A

Personal details of the person for whom the referral applies to:

Required
Required
Required
Date of birth Required
Invalid date
Required
Home address Required
Required
Marital status Required
Type of residence Required
Required
Interpreter needed? Required
Required
Open to RIO? Required
Required
Required
Address (if different)
Required
GP address Required
Required

Name and contact details of Referrer:

Required
Required
Address Required
Required
Required

Reason for referral:

Include the reason why the request is being made at this time. 

Please comment on:

  • Difficulties with social interactions and relationships
  • Intense interests 
  • Repetitive behaviours or routines 
  • Difficulties with change
  • Sensory differences
Required
Is there any legal status which applies to this person? Eg. Mental Health Act, MAPPA Required

Please tick any of the following services which are currently involved with the person or have been in the past:

Mental health services Required
Day services Required
Psychiatry Required
Short break services Required
Psychology Required
Advocacy Required
Physiotherapy Required
Speech and language therapy Required
Occupational therapy Required
Children's services Required
Voluntary/Private care provider Required
Required

Please give details of any other people in the person’s life who may be useful for us to contact eg. other family members/ main carer/ day placement/other professionals:

Address
Address
Address
Diagnosis: Does the person have a learning disability? Required
Is there a diagnosis of autism, ASD? Required

Current physical and mental health: 

Required
Have there been any previous admissions to learning disability or mental health inpatient services? Required

Part B

Does the person present a risk to the safety of people working with them, either in the past or at present? Required
Does the person present with a risk to the safety of others, either in the past or at present? Required
Does the person present a risk to their own safety and wellbeing, either in the past or at present? Required

Part C

Required

Part D

Does the person have capacity to consent to this referral? Required
If they have capacity, have they consented to this referral? Required
Does the person have access to advocacy services? Required
Will the person consider online consultation? Required

For online consultation, you will need access to a computer/tablet/smartphone, with microphone, camera & Wi-Fi. 

Required
Signature of person making the referral Required
Date of referral Required
Invalid date
Required

For completion by the person being referred : consent to share information with other agencies:

Consent to seek and give information

To help us assess your needs, we may need to ask for and share information with other agencies. Please sign if you agree that we can do this. 

I give my consent to share information with other agencies except those listed below: Required

Exceptions

There may be some agencies that you do not want us to contact or share information with. 

Signature
Date Required
Invalid date

Forms may be returned to the referrer if all relevant sections are not completed.

Required