(To be completed by ALL referrers) Name of Service User: Completed by: Date of birth: Profession: Address: Date of referral: Has this service user been seen by CTPLD before? Y / N Should two workers attend for the first visit? Y/N Please explain why If there are indications that there is a risk or potential risk present in the following areas, please circle YES or NO. If YES, then complete the details in the appropriate sections. Referrers may attach separate specific risk assessments if these have been done. Regarding the Person’s Environment Parking/Access YES / NO Physical hazards (e.g. hazardous surfaces) YES / NO Lighting YES / NO Lifts or stairways YES / NO Electrical Safety YES / NO Other environmental hazards YES / NO (e.g., dogs, snakes, infection issues/concerns) YES / NO Regarding the Person: Behaviour of service user or (including violent incidents) YES / NO Mental health problems (e.g. acute anxiety states) YES / NO Physical health problems YES / NO Transport or Mobility issues YES / NO Communication/Dietary/Medication issues YES / NO Manual Handling Risk YES / NO Infections/open wounds etc YES / NO
(To be completed by ALL referrers) Name of Service User: Completed by: Date of birth: Profession: Address: Date of referral: Has this service user been seen by CTPLD before? Y / N Should two workers attend for the first visit? Y/N Please explain why If there are indications that there is a risk or potential risk present in the following areas, please circle YES or NO. If YES, then complete the details in the appropriate sections. Referrers may attach separate specific risk assessments if these have been done. Regarding the Person’s Environment Parking/Access Physical hazards (e.g. hazardous surfaces) Lighting Lifts or stairways Electrical Safety Other environmental hazards (e.g., dogs, snakes, infection issues/concerns) YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO Regarding the Person: Behaviour of service user or (including violent incidents) Mental health problems (e.g. acute anxiety states) Physical health problems Transport or Mobility issues Communication/Dietary/Medication issues Manual Handling Risk Infections/open wounds etc YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO
CTPLD-Referral-Form-August-2016.docx