Secure Outreach Transition Team Referral Form :: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Date of referral Required

Client Details

Name Required

Date of Birth Required

Contact number Required

Rio number Required

NHS number Required

Care coordinator Required

N.O.K or Carer Required

Address Required

GP Practice Required

Has the person consented to the referral or if they lack capacity is it in their Best Interest, who was involved? Required

Consent given

Best interest

Does the client have a learning disability? Required

Yes

Does the client have a diagnosis of Autism? Required

Yes

Background (including any forensic history) Required

Reason For Referral / Concerning Issues Required

What interventions/approaches have been explored previously Required

Risk factors to be considered (historical or current) Required

What support is required from SOTT? Required

Name Required

Contact details Required

Relationship/role Required

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