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If you have a Discharge Summary / Consultant Clinical Letter for the patient, please check the box and upload it below. If not, leave it unchecked and continue with the patient details.
Service(s) Referring To
Sub Service Referral Source Reason for Referral Urgency

Patient details

This section must be completed in full or the referral will be rejected
Housebound(i.e. unable to leave their home, or requiring significant assistance to do so due to frailty, surgery, mental ill health or being at the end of life).
Next Of Kin
Referrer Details
Please provide a generic email address instead of a personal one (NOTE: This email needs to be manned)

Reason for referral (s) Referral will be delayed if this section is incomplete or if reason for referral does not relate to all functions selected above. Please include therapy goals, a summary of medical history and medications. Guidance on what information is required by each service is available on the NELFT website.
Referral
Risks(Can select zero one or many)
Client disability
Domiciliary care agencies/Housing/Social Services
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Diabetes

Please ensure patient has had bloods taken in the last 3 months.

Continence

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Diabetic Foot Protection Service

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Community Podiatry

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Neurological Nursing

Nutrition And Dietetics

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Only MS Word and PDF documents are permitted.(*.dot, *.doc, *.wbk, *.docx, *.docm, *.dotx, *.dotm, *.pdf)
You can attach multiple files, but please note if any are done incorrectly, please click the 'Choose Files' button, and reselect the correct documents
Only MS Word and PDF documents are permitted.(*.dot, *.doc, *.wbk, *.docx, *.docm, *.dotx, *.dotm, *.pdf)
You can attach multiple files, but please note if any are done incorrectly, please click the 'Choose Files' button, and reselect the correct documents
Only MS Word and PDF documents are permitted.(*.dot, *.doc, *.wbk, *.docx, *.docm, *.dotx, *.dotm, *.pdf)
You can attach multiple files, but please note if any are done incorrectly, please click the 'Choose Files' button, and reselect the correct documents

Swallow And Communication

Community Matrons / Case Management

Speech and Language Therapy

          
          
          
Swallowing

Contingent questions for Swallowing.

          
          
          
          
          
          
          
          
Current oral intake according to IDDSI framework (International Dysphagia Diet Standardisation Initiative). Please check all that apply, click on box to check
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
Only MS Word and PDF documents are permitted.(*.dot, *.doc, *.wbk, *.docx, *.docm, *.dotx, *.dotm, *.pdf)
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Communication

Contingent questions for Communication.

          
          
          

Language difficulties (e.g. dysphasia, word finding difficulties)

Other

Slurred speech (e.g. dysarthria)

Voice

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Stroke

Tissue Viability Service

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District Nursing Service

For referral for medicines administration please complete the appropriate NELFT direction to administer form and return with the referral form. If this is not attached this will cause delay in processing your referral.
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Orthotics

Therapy Rehabilitation Service

          
          
          
Medical History/Condition
Add Option
          
          
          
          
          
          
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Community Cardiology Service

NOTE: If patient has chest pain, please refer to RACPC or call 999

Respiratory

SPIROMETRY – PLEASE INCLUDE ALL PREVIOUS READINGS OR ATTACH COPY OF TEST RESULTS

PEAK FLOW RECORDING IF APPROPRIATE
(PLEASE ENSURE CXR IS DONE WITHIN THE PAST 3 MONTHS)
Please attach the following or referral will be delayed



Musculoskeletal Services (MSK)

Environmental Controls

Diagnosis

Alternative Contact (for Client)

          
          
          
          
          

Care Agency

Community OT (if not referrer)

Housing Association/Landlord Details/Council

Social Services OT (if not referrer – i.e. responsible for arranging minor adaptations if required for EC provision)

Speech and Language Therapist

Reason For referral

Area of Control Priority Level (1-6)
          
          
          
          

Environment

Seating and Positioning

Mobility

          
          
          
          
          
          

Physical Abilities

Please give an example of what the client is functionally able to do for each of the parts of the body specified below: (hover over each heading for examples)

Head Right Arm Right Hand Right Leg Right Foot Eyes Left Arm Left Hand Left Leg Left Foot

Sensory Impairments

Cognition & Psychological

          
          
          
          
          

Communication

Current experience of using technology

          
          
          
          
          
          
          
          
          

Additional Information

Prosthetics Service

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(Can select one or many)

Amputation details

Amputation Side and Level

Can select multiple entries, but should select at least one
Lower Limb
Lower Limb
Partial Foot
Ankle Disarticulation
Transtibial
Knee Disarticulation
Transfemoral
Hip Disarticulation
Transpelvic
Lower Limb Congenital Deformity
Upper Limb
Upper Limb
Partial Hand
Wrist Disarticulation
Transradial
Elbow Disarticulation
Transhumeral
Shoulder Disarticulation
Transpectoral
Upper Limb Congenital Deformity
(Can select one or many)

Clinical History

Progress after amputation

Mental Health Wellness Teams

(excludes Talking Therapies and Early Intervention in Psychosis Service)

Community Learning Disability Team

Diagnosed Health Needs

Please indicate professional/s they/you have received input from

OLDER ADULT MENTAL HEALTH TEAM AND MEMORY SERVICE

(Please be aware that although we have the capacity to perform a limited number of home visits when needed, most patients will need to be seen at the clinic for at least some of their appointments).

          
          
          
          
          
          
          
          
          
          

Summary of reasons for referral

Investigations to date

(Please note that in line with NICE guidance and agreed local protocols, we ask that routine bloods including (FBC, U&E, LFT, Thyroid, calcium, B12, folate, glucose, cholesterol, ESR or CRP) are performed before or at the point of referral – ideally within the last six months or more recently if symptoms are more acute.)


For memory referrals
/3

(It is extremely helpful if you are able to provide this information because it can greatly speed up the time that it takes for us to organise the relevant investigations and then to provide diagnosis and start treatment if necessary. Please complete the Mini Cog Test below)

Mini Cog Test.docx

Eating Disorders Team

(excludes Talking Therapies and Early Intervention in Psychosis Service)
Details about client’s difficulties

(NOTE: weight & height are mandatory fields, and the referral cannot be processed without this information height and weight to be measured without wearing shoes)

Psychotropic Deprescribing Clinic


Perinatal Parent / Infant Mental Health Service

Children: (Include full names & DOBs)
First Name Surname Gender Date of Birth Where Living Who With Actions

Psychiatric History (Include family history if known)

Obstetric history

Potential Stressors (detail problems in the areas listed - Yes or No or Not Known)

Known Risks (detail any evidence of risk in the areas listed - Yes or No or Not Known)