Please complete the required fields to continue.
Date of Referral
Are you referring yourself?
Which area does the patient live in?
Have they had a learning disability since childhood?
Name of patient being referred
Date of birth
Age :
NHS number
Address
Contact Number of patient or their carer
Email address
GP Practice
Next of Kin
Does anyone have legal decision making powers?
Power of Attorney
Interpreter required?
Are you aware of any reason why a lone worker should not visit?
Are you aware of any infection control requirements for the patient being referred?
Do you consent to sharing information in and out of the service?
Has the patient consented to the referral?
What is your name?
What is your relationship/role to the patient being referred?
Please provide your contact number
Please provide your email address if you would like an acknowledgement
Is this referral for help with communication?
Please describe the problem of concern with communication and its history:
Is this a new problem for you?
Is help needed with capacity assessment / best interests decision?
Please describe the problem of concern with capacity / best interest decisions and its history:
Is this referral for help with eating / drinking / swallowing?
Please describe the problem of concern with eating / drinking / swallowing and its history:
Is there increased / frequent coughing on food and / or fluids?
Who observed coughing episodes:
Are there frequent chest infections?
List recent episodes of chest infections requiring antibiotics:
Is there reduced food / fluid intake?
Is there reduced ability to take medication?
Has there been any choking episodes?
Who observed choking episodes:
What have you tried so far to help the situation?
Please provide any relevant medical history
Please provide any relevant information about the patients home situation
