Dementia or nursing referral

Fill in this referral form and a friendly member of our team will get in touch with you within 2 working days, to take some more details and arrange your first appointment.

We are not a crisis service. If you feel at risk of harming yourself, or can't keep yourself safe, please visit our ‘Get urgent help’ page for emergency contacts.

Step 1

Introduction

Are you a health or social care professional?*

Yes

No

Has the service user consented for referral to our registered services?*

Yes

No

Does the service user have the mental capacity to make informed decisions about their mental health care and treatment?*

Yes

No

Our Adult and Older Adult registered services only accept referrals from professionals. We're very sorry for any inconvenience caused.

If you are a service user, relative or carer please discuss your/your relative's needs with a health or social care professional.

We're not able to accept referrals without consent where the service user retains capacity to make informed decisions about their mental health care and treatment.

We're very sorry for any inconvenience caused. If you would like to discuss this referral further please contact us:

Email us at referrals.everyturn@nhs.net

Call us on 0191 414 8374

Referrer Details

Please tell us who has consented to the referral on the service user's behalf:*

Your name:*

Your role:*

Your team/service:*

Your telephone:*

Your email:*

Service User Details

Title:*

First name:*

Last name:*

Date of Birth: *

Gender: *

NHS Number:*

Ethnicity/Religion:*

Address Line 1:*

Postcode:*

Telephone:*

Service User Next of Kin Details

Next of Kin Name:*

Telephone:*

Address Line 1:*

Postcode:*

Relationship to Service User:*

Continue to the next step

Step 2

Health & Social Care Details

Health & Social Care Service Involvement

GP Details:*

Consultant Psychiatrist / CPN:

Is the service user admitted to hospital, or living in a care home?*

Yes

No

Care Home / Ward Name:*

Discharge/Notice Date

Do you want to refer the service user to our Adult or Older Person's Registered Services?*

Adult

Older Persons

Which of our Older Persons Services would you like to refer the service user to?: *

Which of our Adult Services would you like to refer the service user to?*

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Continue to the next step

Step 3

Referral Urgency

Is this an urgent referral?*

Urgent referrals usually present with complex symptoms or rapidly changing circumstances and require a quicker response. Routine referrals usually do not present with immediate needs and can be responded to with less urgency.

Yes

No

Referral Details

Primary Diagnoses:*

Secondary Diagnoses:

Key factors for referral (presenting issues, risk, family/carers) :*

Are there any risks to visiting the service user at home?*

Yes

No

Please provide more information on the risks :*

Referral Attachments

Please attach any documents which support your referral including any risk assessments or other assessment documentation. (Word documents and pdf's only)

We aim to respond to new referrals within 24 hours to confirm receipt and next steps.

If your referral is urgent we will offer a rapid assessment according to the service user's needs.

If you would like to speak to one of the team about this referral, you can contact us in one of the following ways:

Email us at referrals.everyturn@nhs.net

Call us on 0191 414 8374

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Submit referral form