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DA Referral form

Use the form below to refer a patient to the programme.

Introduction Guidance

Welcome to the Wellbeing Programme . Even though we work closely with mental health organisations, sometimes the client being referred may need to be signposted to specialist services.
We do not accept referrals for;
1. Clients who have been reported for domestic abuse behaviours historically or present, as we are a victim focused organisation.
2. Clients who score gold unless they will remain an open case with a worker, until the risk reduces.

Please confirm the person being referred has the appropriate risk management (Mental health /DA) in place to ensure they can engage efficiently with the wellbeing service.

This referral cannot be submitted unless the above information is confirmed. By ticking this box, you are ensuring that the risk information shared is correct and up to date. Any Risk information is required to be shared from you to our organisation as part of the referral process and safeguarding procedures.
Guidance for referrers;

Please check the mental health state of the client first. This includes seeing if a client is at risk of harming themselves or others, (suicidal, self-harm , past suicide or current attempts). If so, please contact the mental health crisis team @ 0800 051 1508.

Please share a leaflet and the link to the animation on the S2S website with the client in advance.

If you are unsure of whether the person you are referring is appropriate for the service, please feel free to email us on twp.sthelens@nhs.net

Please complete the below form with as much information as possible. We will not disclose issues discussed without the consent of the service user.

Has the client given consent to be contacted?

Yes No

Client contact number

GP Telephone number:

Best way to contact and any issues around contact?

Is the family open to Social Services ?

Yes No

Pending court case and date due

What was their most recent MERIT Score? (Please attach most up to date copy)

Professional judgement of current risk :

If the case is scored gold, will the case remain open whilst they are being referred and access our service?

Yes No

Clients current living arrangements:

Does the client have any dependent children?

Yes No

If yes, are they open to Children's Social Care (including Early Help)?

Yes No

Is the adult you are referring open to Adult Social Care? If yes please provide details .

Do they have any mental health conditions?

Yes No

Please include any information about if they were diagnosed and when

Any other substance misuse and if known to CGL

Are they on prescribed medication?

Yes No

If yes please specify medication names, amount taken and how often.

Date of last review with GP/Psychiatrist/Mental health worker.

When was the last time the client attended a medication review?

Have they experienced suicidal ideations or made any plans to follow this through recently/historically ?

Yes No

Please specify details if yes and actions taken on this.

Are there any other services supporting the client being referred at the moment or historically?

Yes No

Additional information: