Fields marked * are required.
If you have a Discharge Summary 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
This section must be completed in full or the referral will be rejected, with patient details
Referrer Details
Please provide a generic email address instead of a personal one

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
(Can select zero one or many)
Client disability
Next Of Kin
Domiciliary care agencies/Housing/Social Services
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

Diabetes

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

Continence

Foot Health Diabetes

Foot Health Podiatry

Neurological Nursing

Nutrition And Dietetics

Swallow And Communication

Community Matrons / Case Management

Speech and Language Therapy

Stroke

Tissue Viability Service

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.

Orthotics

Therapy Rehabilitation Service

Community Heart 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



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)