Cassel hospital referral form
Date of referral
Date
Which service do you think would be most appropriate for your patient? (Following screening and discussion we may recommend a different service)
* Required
It is a requirement that all referrals to the Cassel, need to go through (and be discussed with/approved by) the NHS England Regional Commissioner for the client.
Has this referral been discussed and agreed with your NHS England Regional Commissioner?
* Required
If 'Yes', please provide further details:
Name of Local Mental Health Commissioner
Contact telephone number of Local Mental Health Commissioner
Email address
Patient details
Patient name
Gender
** None Male Female Non-binary Prefer not to say
Date of birth
Date
Age
Does the patient have a disability?
Address
NHS number (If known)
Please select ethnic group
** None English/Welsh/Scottish/Northern Irish/British Irish Gypsy or Irish Traveller Any other White background, please describe White and Black Caribbean White and Black African White and Asian Any other Mixed/Multiple ethnic background, please describe Indian Pakistani Bangladeshi Chinese Any other Asian background, please describe African Caribbean Any other Black/African/Caribbean background, please describe Arab Any other ethnic group, please describe
(Please describe if required)
Contact telephone number
RiO number (if West London patient)
Dependents details (Please include ages)
Carers details
Referrer details
Referrer name
Role / organisation
Address
Contact number
* Required
Contact email address
* Required
Care co-ordinator name
Care co-ordinator contact details
* Required
Psychiatrist name
Psychiatrist contact details
Other agencies/individuals involved
(For example, housing, probation, social services, voluntary sector)
Reason for referral
(Please describe current difficulties including diagnosis, risk factors etc. as well as the patient’s thoughts about this referral)
Current care plan or treatment model
Psychiatric history
(Please provide a summary of the patient’s contact(s) with mental health services, beginning with the first presentation. Please include precipitating factors/risk behaviours and note the patient’s engagement with services if known)
Medical history
(Please include physical health diagnoses, medications, etc.)
Personal and family history
(Please provide a developmental history, including early experiences, significant losses or trauma, quality of family relationships, etc.)
Social history
(Please include education, employment, current living arrangements, forensic history, etc.)
Safeguarding
(Please describe any safeguarding concerns and any previous safeguarding events)
Risk factors
Would the patient be able to attend a one-to-one assessment?
* Required
Please attach any relevant further information
