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Step 1

Eligibility check

Step 2

Your details

Step 1

Eligibility check

Select A Service *

Specialty

Which Together in a Crisis Service is this referral relevant to? Please should choose the service being offered in the relevant area

Which Safe Haven would you like to refer yourself to?

GP Practice

Visit the NHS website to enter your GP practice postcode and check if it is included in our service areas: Check your GP practice.

If you can't find your GP surgery please call us to compete your referral

Please enter the GP practice postcode. If the GP surgery postcode is not known, please call us to compete the referral.

Click here if you are unable to provide the GP details
The referral process may be delayed if the GP details are not known.

Click here if you are not registered with a GP

Confirm eligibility and continue

Step 2

Your details

Referrer details

Are you the service user's GP?

Has the user consented for referral to our services?

Identified needs and history

Is Gender Identity the same as Gender Assigned at Birth? *

Sexual Orientation

What are you preferred pronouns?

Do you live or work in South Tyneside



Can we write to you at this address?

 

Is the person residing in the accommodation specified above?

 

If no, where are they residing?

In the section below, please give the preferred contact details of the person you're referring, alongside any relevant supporting information:

We'll need to be able to contact you to process your referral, so please provide at least one number. If you don't provide a number, your referral might be delayed.
Please ensure you have consented to at least one of these options.

Can we contact you on this number?

Can we contact you on this number?

Can we contact you on this number?

Can we email you at this address?

Next of kin details

Relationship to the person being referred:

Given name

Address

Telephone Number

Email

Permission to contact Next of Kin?

Referrer details

 

Key Factors for referral

Primary mental health diagnosis:

Secondary mental health diagnosis:

Physical health concerns:

Active Medications:

Are there any active safeguarding issues with this person?

If yes, please provide detail:

Please detail any actions taken *

Does the person have any presenting risk of harm to self or others? *

If yes, please provide information:*

Additional factors for referral, eg risks, behaviours, family/carer relations

Can you confirm how urgently we need to respond to this referral?

Planned discharge destination:

Section 117:

Is this person subject to section 117 aftercare under the mental health act?

Out of Area:

Would this person be deemed as an 'out of area' referral? (i.e. they are not registered as a resident within the local authorty area where the service you want them to access is based)

Consent

Do you consent to Everyturn Mental Health Involvement? We are unable to process the referral without your consent.

We are unable to continue referral without consent.

I consent for my record to be anonymously used for secondary data usage.

I consent for my records to be shared with my GP.

Risks in relation to initial assessment/visit

Are there any risk to us visiting the person where they currently reside? If yes, please state: *

Are there any issues in accessing the property where the person currently resides? If yes, please state. *

Additional details that may support the referral can be listed below:

Next of kin details

Relationship to the person being referred:

Given name

Address

Telephone Number

Email

Permission to contact Next of Kin?

Additional discharge details:

Risk and safety

Please tell us about any known risks relating to the person, including any risks of harm to others, including staff. Recent risk assessments are helpful if available.*

Please tell us about any known risks relating to the person.

Please could you provide some extra information

Recent contact with services

Please tell us about any recent contacts with services you have had (e.g. Crisis Team, Ambulance service, Police, GP).

Other relevant professions involved

If phone call or text within 24 hours is not suitable for service user, please provide alternative contact details, including method, named contact etc (optional)

Best time to contact

 

Further Information (Reasons for referral)

Please include details of the presenting problem in relation to distress (e.g. self-harm, low mood, distress etc)

Please include details of any known contributing factors, such as alcohol; relationship problems; finances; employment issues; housing etc., and how the DBI service can support.

Are there any known risks to self, (e.g., suicidal thoughts, self-harm etc.,) risk from others (e.g., physical, sexual, emotional etc.,) or related to substance use?

Response to ‘distress rating question’. Ask the service user to think about when their distress was at its worst today. How would they rate their level of distress at that time, when 0 is no distress and 10 is extreme distress?.

Was the service user under the influence of alcohol or other substances at the time of referral?

Has the information sheet been given to the service user?

Risk to others (to be completed by referrer)

If this service user is known to be violent and it is likely that the safety of the level two provider will be compromised, please provide relevant information.

Which session(s) would the service user like to sign up for? Please be as specific as you can, in order for us to enroll them onto the correct sessions or waiting lists.

Please specify how the service user would like us to stay in touch by selecting all of the methods that apply.

What is the service users employment status?

Does the service user have a disability or long-term health condition? We ask this question to find out whether any reasonable adjustments are required, e.g. wheelchair access, etc.

Has the service user ever received a diagnosis in relation to their mental health?

As part of the enrollment process at the Recovery College, one of our Peer Support Workers will give the service user a call, to both welcome them to the College and to discuss our provision. This call is important and forms an essential part of our enrollment process. Continued attendance at any of our sessions depends upon this call being completed. The service user understands that to continue attending sessions, they must complete this call.

The following four questions allow us to identify where in the wellbeing journey the service user currently sits. This allows us to offer the most appropriate provision, including signposting to other services where appropriate.

Please tick to indicate the service user has read our Code of Conduct. It is essential to the health, safety and wellbeing of both students and staff that they follow the Code and understand that it will be applied at each session they attend, regardless of whether you have read it.
You can read the Code of Conduct by following this link:
https://northumberlandrecoverycollege.co.uk/?documents=nrc-student-pack

PER Number if available

Is the person a carer for anyone?

Does the person have a cognitive impairment that may impact ability to make decisions?

Person making the referral

Is this a self referral?

Is this a referral on behalf of someone else?

If on behalf of someone else does the person know this referral is being made?

May we contact them directly?

Type of organisation (please select the option that applies)

Key people involved: Social Worker/Care Coordinator

Has the Adult been assessed as meting the National Minimum Eligibility Threshold (Care Act 2015)

Does the person have a personal budget?

Service required

Support required/Reason for Referral:

  • Short to Medium Term Interventions. (Funded via the Chain Reaction contract).
  • Designed to be preventative 'light touch' social support to help people engage in meaningful activity and address social isolation.
  • Support to access community groups, lunch and coffee groups to make new friends, improved confidence and wellbeing.
  • An alternative to traditional day services.
  • Short Term Intervention (Funded via the Chain Reaction contract)
  • Up to 12 hours support to address a short-term need (includes 1hr initial assessment and 1 hr administration.
  • Types of support will vary from person to person.
  • 4-week review carried out jointly with Pioneer and Social Worker (Pioneer to book the review date when the initial meeting is completed and advise the Social Worker).
  • Long Term Intervention to address the health and/or other health needs (council funded, subject to financial assessment)
  • 1 to 1 support provided over an agreed number per weekm depending on assessed need (typically 2-3 hrs per week but can vary)
  • Types of support can include, help to manage money, pay bills and budgeting, support with shopping and to prepare healthy meals, support to make phone calls and deal with correspondence, support for those who have hoarding issues as an example.

  • Funded by the client or their family if they are inelligible for council funded support.
  • Types of support provided is tailored to meet the individual need and can include support as detailed in the above sections.
  • Types of support provided is tailored to meet the individual need and can include support as detailed in the above sections.

Risk

Is there any known risk to workers when visiting the Adult alone?

Does the person have any disabilities (please select all that apply)

Data Protection Act

Because of the Data Protection Act we need your agreement to for us to securely hold any personal information (including the information on this form), on a computer and in a filing system. It is our policy that all personal data will be held in accordance with the principles and requirements of Data Protection and other relevant legislation, and that procedures will be put in place to ensure the fair processing of data relating to individuals.

Please indicate agreement has been given for chain reaction to securely hold the information on this form by selecting the check box.

By submitting this form, I consent to my information being shared with Everyturn. This information will be handled securely, in line with the Data Protection Act 2018. For full details, read our privacy policy.

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