HomeFirst LLV Rapid Response Referral **Please complete both sides of form** Date Time information received Referrer name, position & contact no. for next 60 minutes EXCLUSION CRITERIA Medical Emergency Call 999 Life threatening illness Serious injury Psychiatric crisis Refer to HPFT SPA 0300 777 0707 Actively suicidal or self-harming Pregnancy Refer to maternity services End of life Refer to ICT and/or Hospice services Supported discharge Hospital to complete safe discharge NAME DOB Address including postcode Will client be at this address? Tel. number NHS No. GP surgery Reason for Referral Working Diagnosis Presenting problem Plan of care / Aim of Home First Has client seen GP in last 24hrs? If not why not? Last medical assessment date
HomeFirst LLV Rapid Response Referral **Please complete both sides of form** Date Time information received Referrer name, position & contact no. for next 60 minutes EXCLUSION CRITERIA Medical Emergency Life threatening illness Serious injury Call 999 Psychiatric crisis Actively suicidal or self-harming Refer to HPFT SPA 0300 777 0707 Pregnancy Refer to maternity services End of life Refer to ICT and/or Hospice services Supported discharge Hospital to complete safe discharge NAME DOB Address including postcode Will client be at this address? Tel. number NHS No. GP surgery Reason for Referral Working Diagnosis Presenting problem Plan of care / Aim of Home First Has client seen GP in last 24hrs? If not why not? Last medical assessment date
HomeFirst%20Rapid%20Response%20.docx