Waddington Street Centre

3 Waddington Street, Durham. DH1 4BG

www.waddingtoncentre.co.uk

Tel:	0191 3860702 Fax:	0191 3755140

Email:	swakefield@waddingtoncentre.co.uk

Client referral form

Personal details

Surname	First name

D.O.B

Home Address

Post code

Telephone / mobile phone number

Ethnicity

Consultant psychiatrist

GP name

Surgery details

Next of Kin or Carer

Address

Post code

Telephone / mobile phone number

Referral details

**Referrer

Referral date

Referrer’s address

Post code

Telephone / mobile phone number

E.mail

Day/days of attendance (2 days maximum)

Sharing information – Agreement form

In order to fully understand your situation, it will be helpful to discuss with some other agencies and people what they know about you. We will only ask them about matters, which concern your health and care needs. It may also be necessary to share with them information we have about you. We do need your permission to do so and we will not act against your wishes.

We will respect the confidentiality of any information shared with other agencies.

The following are the agencies and people who generally are able to help. Please indicate those, which you agree we can contact.

Durham County Council Children and Adults staff

Tees Esk and Wear Valley NHS Trust staff

GP surgery staff

............................................................	..............................................

Client signature	Date

Information from the Referrer (** on page 2)

Reason for referral including diagnosis

Leisure pursuits

What does the client enjoy in the form of:

Hobbies / interests?

Relaxation?

Motivation?

Physical activity?

Education?

Interpersonal skills

How does the client cope with:

Communication?

Large or small groups?

Medical / psychiatric problems

YES	NO

Does the client suffer from any medical or

psychiatric condition which would require

precautions during the routine activities

offered at WSC?

If the answer is YES, give details below.

Use of alcohol and drug abuse

YES	NO

Doe the client have a known history of problem

or using illicit drugs?

If the answer is YES, give details below.

Relevant past / personal history

Family history e.g. parents, siblings

Current employment (if any)

Past employment/voluntary work (if any)

Risk Assessment

Is there a personal risk of:

Suicide	Choose an item.

Self harm	Choose an item.

Self neglect	Choose an item.

Neglect or abuse	Choose an item.

If yes to any, please elaborate outlining the nature of the identified risks, contributory factors and relevant history.

Does the client present risk to others of:

Violence	Choose an item.

Aggressive behaviour	Choose an item.

Anti social behaviour	Choose an item.

Neglect or abuse	Choose an item.

Fire	Choose an item.

Other (please specify)	Choose an item.

If yes to any, please elaborate outlining the nature of the identified risks, contributory factors and relevant history.

Are there any previous criminal issues that WSC should be aware of?

Type of case: (please indicate)

Standard care co-ordination

Enhanced care co-ordination

Section 117

Payment method (please indicate)

Service level contract

Spot purchase

Direct payment (via personalisation)

Virtual budget (via personalisation)

GP commissioning

South Durham Affective Team Project

Please return the completed form to:

Steve Wakefield, Centre Manager

Waddington Street Centre, 3 Waddington Street, Durham. DH1 4BG