If you are unclear about referral criteria, please contact us - RADS@cntw.nhs.uk or 0191 246 8606

Patient Demographics

(Compulsory)

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Is the patient aware of and agreeable to referral? Required

GP Details

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Care Coordinator/CTT professional details

(necessary for referral to be accepted)

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Details of Other Professionals Involved in Care

Is the patient accessing mental health care with another service?

If so, which service? Enter the details below.

Additional details

Is the patient currently admitted to a hospital? Required
For the assessment, will the patient be able to travel to the Newcastle Wolfson Research Centre? Required

Referrer details

Enter the details of the referrer below.

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I wish to refer to the service for
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Please set out also your and the patient’s - rationale and expectation for the referral

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Please provide us with a clinical history, we would like a description of the current episode and it’s time course and attributing factors. With a social history, family history, past medical history, past psychiatric history. A review of previously and currently used psychological and biological treatments and forensic history. Please be aware that if the patient is not a CNTW patient then we won’t have access to medical notes. 

Please include in detail - current symptoms, duration, summary of medication history including combinations and augmentations trialled as well as doses, durations, and tolerability, summary of psychological therapies trialled including duration/number of sessions, and summary of physical treatments

Please include in detail

Past Psych history Required

If the patient is in CNTW please confirm that the narrative risk assessment section of RiO is up to date. If not, please provide a risk assessment and management plan.

(including social networks and supports)

(please include any criminal convictions or any pending court appearances/charges)

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Include date and any abnormalities

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Does the patient need an interpreter?
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