Community Learning Disability Team referral form

Referral criteria

Adults aged 18 and over who have a mild, moderate, severe or profound learning disability who need specialist assessment or interventions.
People who have learning disabilities that significantly impact on being able to live their lives independently.
People whose actions or behaviours significantly impacts on their inclusion and integration into mainstream services or activities in everyday life.
People who have a learning disability and are in transition from children’s to adult services – from 17½ years-old.

Does the person have a learning disability?*

Yes
No
Unsure

Screening checklist

Does the person have...

A significantly reduced ability to understand new or complex information to learn new skills*

Yes
No

A significantly reduced ability to cope independently*

Yes
No

The above is apparent before adulthood is reached and has a lasting effect on development*

Yes
No

The person is able to access health services within mainstream/generic services for the identified need(s) which you are referring them for?*

Yes
No

People with a learning disability should be supported/encouraged to access mainstream services for their healthcare.

Based on the information provided, the person you are referring would not be eligible to our services. If you require further support or have any queries, please contact us on 0300 123 4195.

Person being referred

Firstname*

Surname*

Hidden

OLD Name

First name Surname

Date of birth*

Address*

Address line 1 Address line 2 Town County Postcode

NHS number

Phone*

Gender*

Ethnicity*

Other, please specify*

Referrer details

Referred by*

First name Surname

Role/relationship/position*

Address*

Address line 1 Address line 2 Town County Postcode

Email*

Phone*

Next of kin / nearest relative / significant other

Hidden

OLD Name

First name Surname

First name*

Surname*

Relationship*

Hidden

OLD Relationship

Address*

Address line 1 Address line 2 Town County Postcode

Email

Phone*

General practitioner (GP)

This section must be completed.

Named GP (if known)

GP surgery*

Other, please specify*

GP practice name Address line 1 Town County Postcode

Relevant contacts and support networks

List

Name	Title/relation	Organisation (if relevant)	Email	Phone

Area of need/Intervention required

Please be reminded we are not a mental health service. If your referral relates to an individual who is a suicide risk or who has a primary mental health need, please ensure you refer to the appropriate service to manage this particular need.

In your opinion, is this an urgent referral?*

Yes
No

Please tell us the one key/priority reason for this referral to the community learning disability team*

Are you also making a referral for another reason that requires intervention from the community learning disability team*

Yes
No

Other reason(s) for referral

Hidden

OLD Other

Referral information

Information about the person being referred*

Are there medical or mental health issues, conditions or diagnosis? Is there anything you’d like to tell us about their support needs or living situation? Are there any significant life events or recent changes we should know about? Are there any cultural needs you’d like us to be aware of? How does the person communicate best? Are there any specific communication issues such as needing an interpreter?

Information about the areas of need and intended outcomes*

What would you like help with? Describe any concerns the person is having. How long has there been a problem? Is there anything you have already tried? Have you already called us and spoken to someone in our team about this? Is there anything else worrying you? What do you hope would be the outcome for them? How would you like our team to help? What might this person want for themselves?

Risk and safeguarding concerns

Risk to others (for example, physical aggression, verbally abusive, child protection)
Risk from others (for example, vulnerability, safeguarding, exploitation, neglect)
Risk to self (for example, self-harm, self-neglect, suicidal thoughts)

Additional risk and/or safeguarding information

Please do share/attach extra information if needed

Accepted file types: jpg, docx, pdf, png, xlsx, Max. file size: 50 MB.

Consent

Consent*

The person being referred is aware of the referral and has given consent
The person being referred is not aware of the referral

Please explain why the person being referred is unaware of the referral

After clicking submit, please wait for the confirmation page which will provide you with a reference number. You should hear from us within two weeks, however if your referral is urgent, please contact us at 0300 123 4195.

Recommended

Services

Pages

Leaflets

Community Learning Disability Team referral form

Your information

Referral criteria

Screening checklist

Person being referred

Referrer details

Next of kin / nearest relative / significant other

General practitioner (GP)

Relevant contacts and support networks

Area of need/Intervention required

Referral information

Consent