Mental Health & Deafness Service Referral Form

Client details

Patient Contact

Person Making this Referral

Please include best way to contact Referring Service/Care Coordinator

General Practitioner (GP) details

Additional People Involved with the Client

Please provide us with details regarding client’s mode of communication, e.g. BSL user, spoken language, etc. If the client has a preferred interpreter, then please provide this information here. Please also comment on the cause of deafness and age of onset of deafness. 

Please include presenting problems, clinical signs and symptoms, etc. 

Please give an overview of the client’s expectations for the referral and what their understanding is of what the service will support.

Please detail any information that would need to be taken into consideration, e.g. harm to self and or/others, infection control risks, safeguarding, rural setting, allergies, etc.

Consent

Relevant Documentation

Please note we are a regional service and may not have access to your record system. We require accurate up to date information in order to provide the best support to your service and the patient.