Kirklees Mental Health - Older Peoples Referral Form

Screening Questions

1) Is the service user expressing suicidal thoughts?

a) Can the service user keep themselves safe and for how long?

b) What plans has the service got in place to take their own life or to keep themselves safe?

c) Is the service user on their own or is there someone with them?

2) Does the service user feel like they want to harm themselves in anyway?

3) Has the service user displayed or threatened physical aggression resulting in harm or potential harm to themselves, others or property?

4) Is the service user at sever and/or immediate risk to neglect?

5) Is the service user hearing, seeing and believing things that may not be real, which are causing risk and/or high levels of distress to themselves or others?

IF ANSWERED YES TO ANY QUESTION ABOVE please contact 01924 316830 to discuss with a Mental Health Practitioner.

If you are a GP referrer please consider the following:

1) Does the service user present with mild to moderate symptoms of anxiety and/or depression and has no active risk issues please consider referring to IAPT (Improved Access to Psychological Therapies)

IAPT accepts appropriate self - referrals. Phone - 01484 434625

2) If you are referring for a Memory Assessment/Diagnosis, please ensure the following have been completed/ otherwise this may delay the referral being processed: Dementia screening bloods (FBC, U&Es, TFT, Folate and B12, LFT, calcium, lipids, CRP and glucose).

3) Please consider the protocols for older people with dementia, older people with depression and Health & Social Care Protocol for the Assessment, Care and Management of PEOPLE WITH MEMORY CONCERNS (Dementia).

KMH - Older Peoples Referral

Overseas visitor?
Dependants or Caring Responsibility
Social/Personal Circumstances
Job Status:
Reason for Referral: (Tick as appropriate)*
If no, please order and continue with the referral
If no, please order and continue with the referral
If no, please order and continue with the referral
Current Mental Health Presentation
Relevant Medical History
Past Risk History
Referrer Details