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Community Acquired Brain Injury Service (CABIS) – Gateshead, Sunderland and South Tyneside – CNTW102 (Gateshead base)
CABIS Referral Form
Back to Community Acquired Brain Injury Service (CABIS) – Gateshead, Sunderland and South Tyneside – CNTW102 (Gateshead base)
Referral Criteria:
A diagnosis of an Acquired Brain Injury (ABI), not stroke / degenerative condition.
16 years of age or over.
Registered with a GP in Gateshead, Sunderland, or South Tyneside.
The client is considered to be able to engage with neurorehabilitation with realistic goals for change.
Details of the person being referred
Title
*
Required
Forename
*
Required
Surname
*
Required
Date of Birth
*
Required
Ethnicity
*
Required
Address
*
Required
Address 1
Address 2
City
Country
Select a country
Afghanistan
Åland Islands
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Chile
China
Christmas Island
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Greenland
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Guinea-Bissau
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Mali
Malta
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Mayotte
Mexico
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Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
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Panama
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South Africa
South Georgia & South Sandwich Islands
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South Sudan
Spain
Sri Lanka
St Barthélemy
St Helena
St Kitts & Nevis
St Lucia
St Martin
St Pierre & Miquelon
St Vincent & the Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
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Tokelau
Tonga
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Tunisia
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Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
County
Postal Code
Landline
Mobile
NHS number
RiO Number
Next of Kin
Title
*
Required
Forename
*
Required
Surname
*
Required
Relationship to patient
*
Required
Address (if different to above)
Address 1
Address 2
City
Country
Select a country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Ceuta & Melilla
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Diego Garcia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR China
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St Barthélemy
St Helena
St Kitts & Nevis
St Lucia
St Martin
St Pierre & Miquelon
St Vincent & the Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Outlying Islands
US Virgin Islands
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
County
Postal Code
Landline
Mobile
GP details
Name & address
*
Required
Telephone number
*
Required
Referrer details
Name
*
Required
Address
*
Required
Address 1
Address 2
City
Country
Select a country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Ceuta & Melilla
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Diego Garcia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR China
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St Barthélemy
St Helena
St Kitts & Nevis
St Lucia
St Martin
St Pierre & Miquelon
St Vincent & the Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Outlying Islands
US Virgin Islands
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
County
Postal Code
Role of the referrer
*
Required
Telephone number
*
Required
Referral Information
Date of Referral
*
Required
Date of Injury
*
Required
Does the person being referred consent to this referral and to being contacted by staff from CABIS?
*
Required
** None
Yes
No - please give a reason
Reason if no consent given
Is this person currently in hospital?
*
Required
** None
Yes
No
If yes, what is their anticipated discharge date?
Clinical information (please provide as much detail regarding head or brain injury: nature / mechanics, any relevant reports/scans, comorbid conditions)
*
Required
Reason for referral / expectations of referral (i.e. assessment of cognition, rehabilitation in the community, capacity, change in functioning, behaviours that challenge)
*
Required
Known risks
*
Required
Other services involved
*
Required
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