Macmillan Cancer Psychological Support (CaPS) Team Referral Form (Counselling, Clinical Psychology & Liaison Psychiatry) PATIENT DETAILS Date of Referral: Patient / Carer (for carers, provide linked Patient Name/Hospital No. here but carer’s own details in the remainder of the form: ) Surname: Forename: Gender: Hospital No: DOB: Marital Status: Outpatient / Inpatient Ward (if applicable): Planned Discharge date: Consultant(s): Team/MDT: Primary Diagnosis: Current Treatment Status/Plan: Home Address: GP Name/Address/Telephone: Contact Details (Mobile & Landline): REFERRER DETAILS Name: Contact details (including telephone no.): Professional Role: INCLUSION CRITERIA Please ensure that the patient you are referring: Is being referred for psychological issues related to cancer or impacting upon cancer treatment Has consented to be seen by our service (please call/bleep if consent cannot be established) Is 18 years old or over Is or has been the care of (or a carer for someone at) St George’s being treated for cancer Is able to communicate (e.g. through speech, writing, drawing) PRIORITY LEVEL URGENT ADVICE/ASSESSMENT Please make an assessment of need before If you require urgent advice/assessment, please making a referral distress is not in of itself an 7737 initially (and follow this with a completed form after – appropriate reason for specialist psychological speaking to one of our team). Using this form alone will support. Do consider the duration and severity of not get you an urgent response. difficulties and contact us if unsure. Routine patient referrals may be placed on waiting list. Reasons may include: Routine Risk of suicide/self-harm/harm to others Priority e.g. issue compromising medical Treatment refusal (conduct a capacity assessment care days/weeks from end of life Active psychotic symptoms e.g. suspected risk of hallucinations/delusions (discuss with medical team prior to bleeping) REASONS FOR REFERRAL Summarise the reason for referral here: Please tick as many as you feel apply: Suicidal ideation/risk Relationship issues Active psychosis e.g. hallucinations/delusions Carer burden Treatment refusal Support with issues relating to children < 18
Macmillan Cancer Psychological Support (CaPS) Team Referral Form (Counselling, Clinical Psychology & Liaison Psychiatry) PATIENT DETAILS Date of Referral: Patient / Carer (for carers, provide linked Patient Name/Hospital No. here but carer’s own details in the remainder of the form: ) Surname: Forename: Gender: Hospital No: DOB: Marital Status: Outpatient / Inpatient Ward (if applicable): Planned Discharge date: Consultant(s): Team/MDT: Primary Diagnosis: Current Treatment Status/Plan: Home Address: GP Name/Address/Telephone: Contact Details (Mobile & Landline): REFERRER DETAILS Name: Professional Role: Contact details (including telephone no.): INCLUSION CRITERIA Please ensure that the patient you are referring: Is being referred for psychological issues related to cancer or impacting upon cancer treatment Has consented to be seen by our service (please call/bleep if consent cannot be established) Is 18 years old or over Is or has been the care of (or a carer for someone at) St George’s being treated for cancer Is able to communicate (e.g. through speech, writing, drawing) PRIORITY LEVEL URGENT ADVICE/ASSESSMENT Please make an assessment of need before making a referral – distress is not in of itself an appropriate reason for specialist psychological support. Do consider the duration and severity of difficulties and contact us if unsure. Routine patient referrals may be placed on waiting list. Routine Priority e.g. issue compromising medical care days/weeks from end of life suspected risk of If you require urgent advice/assessment, please 7737 initially (and follow this with a completed form after speaking to one of our team). Using this form alone will not get you an urgent response. Reasons may include: Risk of suicide/self-harm/harm to others Treatment refusal (conduct a capacity assessment Active psychotic symptoms e.g. hallucinations/delusions (discuss with medical team prior to bleeping) REASONS FOR REFERRAL Summarise the reason for referral here: Please tick as many as you feel apply: Suicidal ideation/risk Active psychosis e.g. hallucinations/delusions Treatment refusal Relationship issues Carer burden Support with issues relating to children < 18