REDBRIDGE & WALTHAM FOREST

							                          REDBRIDGE & WALTHAM FOREST
                        LEARNING DISABILITIES PARTNERSHIP
                  SERVICE FOR PEOPLE WITH LEARNING DISABILITIES

This service keeps a record of all referrals made to us. It is also discussed openly at a Multi-
professional/agency meeting. Subject to certain legal restrictions all correspondence can be seen by
the client to whom it pertains. If you do not wish for this team to see your information without your
consent you should specify this.

                                         REFERRAL FORM

NAME:          ……………………………………………………………. D.O.B. .……………

ADDRESS: ………………………………………………………………………………………

TEL. NO:       …………………….. Male/Female ……………….. ETHNICITY ………….P.T.O.

G.P. DETAILS: ………………………………………………………………………………………..

                                                G.P. Stamp




      Please continue on separate sheets if necessary
      Please attach relevant other information including Behavioural Guidelines, Risk
       Assessment and other reports

Please give details of person’s needs:
……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Relevant additional information: (Challenging needs; sensory or physical disability; mental health;
communication etc)
……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………
Has the person being referred been informed about this referral? (Please circle) YES NO
How has the client responded to the referral? (What did they say/do?)

……………………………………………………………………………………………………………

Does the client have a risk assessment                        (Please circle)             YES         NO
If they have risk assessments can copies be sent with the referral form
Does the client have a health action plan                   (Please circle) YES    NO

What other services/agencies/key people are involved?
……………………………………………………………………………………………………………

……………………………………………………………………………………………………………


 Please note that if the referral form is not written clearly or is not completed in full it
                   will be returned to the person making the referral

REFERRER INFORMATION/DETAILS
I agree to pass on information and support the C.L.D.T. members in the process of this
referral and the resulting work

Name and position of referrer:    Daniel Wilson…………………………………………………

Signature: ………………………………………………………………………………………………

Contact address & Tel.No: 30 Coleridge Rd, Walthamstow, London E17 6QU
……………………………………………………………………………

Date of referral: ……………………… Date referral received: …………………..

Return address:     REFERRAL OFFICER, CLDT, 30 Coleridge Road, Walthamstow,
                    London E17 6QU

OFFICE USE ONLY: SERVICES REFERRAL ALLOCATED TO:




ETHNICITY OPTIONS


WHITE = 1; BLACK-CARIBBEAN = 2; BLACK-AFRICAN = 3; INDIAN = 4; PAKISTAN = 5;

BANGLADESHI = 6; CHINESE = 7; BLACK-OTHER = 8; ANY OTHER – 9