zilongwang/ReadingBank huggingface dataset:
STRICTLY CONFIDENTIAL Promoting good mental health through personal development, education and employment REFERRAL TO PENTREATH Please complete this form if you wish to access our vocational services. You can find additional information on our website www.pentreath.co.uk or contact us on: 01726 862727 or info@pentreath.co.uk Please return this form to: Pentreath Ltd, St Enoder Barns, Narrow Lane, Summercourt, Newquay TR8 5EE Information About You: Full Name Date of Address Postcode Phone Landline Mobile Email Preferred Contact Phone Letter Email Initial contact will be by telephone Language If you need a translator, please state language required. NHS Number Gender Male / Female/ NI Number Please give details of your diagnosis/mental health problem: Do you have any additional needs which you feel we should know about? Please tick as many as apply to you, this will help us to identify funding to support you. Employed On Sick Leave At risk of losing Job Want to change Unemployed Less than 6 months 6 months to 1 year Over 1 year Never worked Education No qualifications Less than 5 GCSE’s More than 5 GCSE’s 2 A levels or Benefits ESA Ex-Military Single Parent Homeless Ex-offender Universal Credit Ethnicity Please tick the option which indicates your cultural background ( Prefer not to say) Income Support or Asian British Black or Black British White Other JSA Bangladeshi African British Not known Other: Indian Caribbean Gypsy Declaration I confirm that the information on this form is accurate and correct. I am willing for this information to be held by Pentreath Ltd. Pakistani White+Asian Irish Chinese Other Other Other Signed Date / / _ Pentreath is registered under the Data Protection Act. Your information will be held for auditing and funding purposes. What You Want What sort of support do you want from Pentreath? Please give details if you can.
What goals do you have? Please give details if you can. Employment, Education/Training, Volunteering, Recreational Activity, Other............. Your Current Support. Are you getting support from organisations? Community Mental Health Team Social Care / Cornwall Council Outlook South West Employment Services Post Natal Depression Learning Disability Services GP Drug/Alcohol Team Peer Support Groups Please tell us the name of your GP and surgery you go to. GP Name GP Surgery Is there a keyworker/clinician/family member we should talk to about your support? Name and Role Contact Number Referring Agent If someone else is referring you, their details go here. Referrer Name: Contact Address Post Code Telephone Job Role: Clinician , GP , Counsellor , Probation Officer , Advisor , Other Organisation: GP , CMHT , OSW , Addaction , Social Care , Probation Services/CRC , CAMHS , Jobcentre , Voluntary Sector , RCHT , Other Primary Health Care , Other Secondary Care , Other Pentreath Section (Office use only) Approved: Yes , No Signature: ...................... Date: .............................. Date Received: Client ID: ................... Admin: ....................... Date: ..........................
EXTERNAL AGENCIES INVOLVED How have external agencies been involved? Eg: CAMHs, Education Psychologist, Social Care, Speech & Language. (Please indicate nature of involvement, names, dates & contact numbers) Prioritise the 3 BEHAVIOURS OF CONCERN the student gets involved in [1 worst, 2, 3 etc]: Threatening Behaviour to Staff Verbal Abuse to staff Verbal Abuse to Peers Threatening Behaviour to Peers Physical Aggression to Peers Self Harming Physical Aggression to Staff Absconding from the Classroom/School Building Persistent Classroom Disruption Damage to Property Truancy Theft Racism Sexualised behaviours Bullying
Depressed Running out of classroom or building Difficulty focusing on learning Other If the child has been diagnosed with any of the following, please provide dates and person who completed diagnosis and attach copy of paperwork DIAGNOSIS TICK Name & Date ADHD ASC ODD CONDUCT DISORDER ATTACHMENT/EARLY TRAUMA EDUCATIONAL SUPPORT e.g. DYSLEXIA, READING RECOVERY SPEECH & LANGUAGE Academic Levels Reading Writing Maths
Name: Contact: Suburb: Family Composition: Language if required: Visa and Income Details: Finally Determined ⃝ Departure ⃝ TPV ⃝ SHEV ⃝ Does the person have Work rights? ⃝ Does the person have Medicare? ⃝ Is anyone in the family working? ⃝ If there is any income in the family, how much per week? $.......................... Please list needs: ______________________________________________________________________________________ Closest Hub being referred to: Goodna (Monday afternoon) Logan (Tuesday all day) Romero Centre (Wednesday afternoon) Indooroopilly (Thursday afternoon) Contact details of Referrer: Organisation: __________________________________________ Name of Referrer:_______________________________________ Contact Email:_______________________________________
Ethnic Origin (Please tick the appropriate box) White British White Irish White Other Black British Caribbean Black African British Indian Pakistani Other Mixed Black/White Caribbean Black/White African Mixed Asian/White Other ethnicity Prefer not to say Religion (Please tick the appropriate box) Christian Buddhist Hindu Jewish Muslim Sikh No religion religion Prefer not to say Gender (please tick the appropriate box) Male Female Prefer not to say Do you identify as transgender? Yes No Prefer not to say Sexual Orientation (please tick the appropriate box) Heterosexual (Straight) Gay Lesbian Bisexual Other (please specify if you wish) Do you consider yourself to have a disability? Yes (please specify if you wish) No Prefer not to say opportunity, choice and wellbeing
CONFIDENTIAL KCF EXTERNAL REFERRAL FORM KCF ID NO: NOTES: CLIENT INFORMTION FOR OFFICIAL USE: FULL NAME FULL ADDRESS D.O.B. CONTACT NUM. EMAIL PERSON MAKING REFERRAL NAME CONTACT NUM. EMAIL ORGANISATION DETAILS Has the client agreed to be contacted? REFERRAL INFORMATION Date of Referral Reason: Please note any concern or relevant information below:(e.g. deadlines, special needs, any risk factor…etc) Please email completed forms to For any enquiry call Catherine on 0775 705 6687
First Trainee:- Surname: GMC Number: Date: School/Specialty: Grade: Educational Supervisor: Clinical Supervisor: Training Programme Director: Location (at time of referral): Is the trainee working Less Than Full Time (LTFT)? Yes No Is the trainee currently considered safe to practice? Yes No If you answered no the previous question, have you informed Clinical /Medical Director and HR? Yes No Is the trainee registered with a local GP? Yes No Please tick any of the below where it is felt the trainee is not meeting the required standards and would benefit from further support (based on GMC Good Medical Practice 2013): Knowledge skills and performance Developing and maintaining professional performance Applying knowledge and experience to practice Recording work clearly, accurately and legibly Safety and quality Contributing and complying with systems to protect patients Responding to risks to safety Protecting patients and colleagues from any risk by the trainees health Complying with employer processes and policies Communication, partnership and teamwork Communicating effectively Working collaboratively with colleagues to maintain or improve patients care Teaching, training, supporting and assessing Continuity and coordination of care Establishing and maintaining partnership with patients Maintaining trust Showing respect for patients Treating patients and colleagues fairly and without discrimination Acting with honesty and integrity Progression in training Passing required exam Satisfactory ARCP outcome E-portfolio engagement Please tick any of the below areas which it is felt are impacting on the trainee (if any): Personality Language
Signed (GP/Healthcare Professional): Name (please print): Return this form to: By Post Self Help 1st East Oakland House, 76 Talbot Road Old Trafford, Manchester M16 0PQ By email If you want help accessing our services or wish to cancel an appointment please contact the office between 9:00am – 5:00pm. By telephone: 0161 226 3871 By fax 0161 877 2740
Withdrawn/ isolated Low self esteem Eating difficulties Sleeping difficulties Depressed Anxious / nervous Bed-wetting/soiling Suicidal feelings Self-harming Tearful Difficulty making friends Other, please specify: _____________________ Comment: Hyperactive Concentration/ attention difficulties Anger management Temper tantrums Aggressive behaviour Substance abuse Stealing School refusal Poor social skills Anti-social behaviour Violence Other. Please specify: _________________ Comment: Physical Neglect Emotional Sexual Domestic Violence Other: Please Specify ________________ Comment: Developmental/ Educational Needs Learning Disability Developmental delay Physical disability Speech and Language difficulty Motor delay Any comments: Resource teacher, no of hours______ Special needs assistant Classroom assistant ADHD Dyslexia Dyspraxia Any comments: Parent Family Alcohol/Substance Misuse Parenting alone Mental health problems Separation and Loss Health problems Intellectual/physical disability Parenting difficulties Stress Social isolation Literacy and numeric difficulties Any comments: Financial difficulties Domestic violence Poor housing Social isolation Difficulty with extended family Lack of support Unemployment Child in foster care in residential care Any comments: 3 Section3
Date of Referral: Is client aware of referral? Yes No Is client willing to attend Yes No Referral Type: Walk in Phone Email Fax Referral Source: Self Doctor: _____________________________ School Friend/Family Member Service Provider:_______________________ Client Details Name: Date of Birth: Address: Place of Birth: Suburb: Post Code: Gender: ☐ Male ☐ Gender Diverse ☐ Unsure ☐ Female LGBTIQ+: ☐ Lesbian ☐ Gay ☐ Bisexual ☐ Trans ☐ Intersex ☐ Queer ☐ Other Home Ph # Mobile Ph # Ethnicity: Religion/Spirituality: Health Care Card No: Expiry: Medicare No: Reference: Expiry: Do you suffer from any of the following health conditions? Diabetes Heart Disease Epilepsy Lung Disease Kidney Disease Arthritis Asthma Low/high Blood Pressure Other: ________________________________________________________________________________ Allergies: Reason/s for Referral: Mental Health Drugs and Alcohol School/Work General Health
Details of Injury Date of injury/diagnosis Name of hospital attended Dr / Consultant / Neurosurgeon Acquired Brain Injury: Vascular e.g. stroke, haemorrhage (please give details) Viral e.g. meningitis (please give details) Tumour (please give details) Hypoxic / anoxic (please give details) Encephalitis (please give details) Other (please give details) Traumatic Brain Injury: Road traffic collision (RTC) (please give details) Assault (please give details) Fall (please give details) Other (please give details) Please mark any of the following areas of function the person is having difficulty with as a consequence of their injury: Epilepsy Movement/Mobility Vision Hearing Speech and language Behaviour Emotions Memory Attention/concentration Self-awareness/Insight Problem solving Pain Transfers Fatigue Other difficulties (Please give details): Medical condition: Please give a brief description of any other significant medical condition:
Violence to an adult Violence to property Criminal charges Misuse of drugs or alcohol Absconding Smoking Bullying Fire raising Depression Eating disorder School exclusion Abuse/Trauma History This section of the referral form asks for sensitive information that you may not wish to share at this point of referral. We would understand and respect this action however, it is important that we receive a verbal statement in order to make an informed assessment when considering the most appropriate placement for the young person. Is the young person: NO Please provide significant details
Address: Relationship to adult at risk: If the alleged abuser is a staff/volunteer, provide details (include. employer, job role, work address): Please tick or cross YES NO Are they an adult with care and support needs? Details of care and support needs (if applicable): Any details about the alleged abuser(s): Description of the alleged incident/harm Please give a detailed description of the incident (including times), all people involved, witnesses and any other comments you feel are relevant. If the concern relates to physical abuse please provide a body map. Type of abuse Please tick or cross all that apply Physical Sexual Psychological/emotional Financial/material Neglect/omission Discriminatory Self-neglect Domestic abuse/violence Modern slavery Radicalisation/extremism Other If other, please specify: Please tick or cross UKNOWN YES NO Is the adult at risk of further abuse/neglect? What has been done to ensure the immediate safety of the adult at risk and others? (Completing and submitting this form does not constitute management of immediate risks). Please tick or cross YES NO Were the Police called? Please provide the outcome of the Police action and Police log number (if available):
Self Referral Form Which service you would like to access? Your Details: Name: Date of Birth: DD / MM / YYYY Address: Male □ Female □ Post Code: NHS Number: You will find you NHS number on: a medical card a letter from your GP or a hospital a printed prescription How we contact you? Landline Number: We will try to contact you by telephone unless otherwise advised. If possible, please provide a mobile number in addition to a landline. Mobile Number: Address: Please tick (a), (b), (c) if you do not give permission. leave a message with someone answering my phone □ a message on my answering machine □ send reminders via text message to your mobile □ Your GP’s Details GP Name: To find your GP address go to Practice Address: Postcode: Practice Tel No: We are required to notify your GP that you are accessing our service. Please provide permission for us to write to your GP with this information. Please note that if you do not give permission we are unable to offer you this service. I give Self Help permission to contact my GP. Yes □ No □ About You Why do you wish to access to this service? Please give details. Yes □ If yes, please give
Have you had a mental health diagnosis from a GP, psychiatrist or other health professional? No □ Are you currently receiving therapy or seeing health care professional? Yes □ If yes, please give details. No □ Are you currently taking medication prescribed by a doctor? Yes □ If yes, please give details. No □ Have you had thoughts of suicide in the last month, which you have wanted to act upon? Yes □ If yes, please give details. No □ Do you take non-prescribed drugs? Yes □ If yes, please give details. No □ Have you been involved with the criminal justice system? Yes □ If yes, please give details. No □ Have you served in the Armed Forces? Yes □ No □ Are you currently pregnant or had a baby in the last 18 months? Yes □ No □ Do you receive regular home visits fro your GP? Yes □ No □ Where did you hear about the service? Please give details. Please outline any specific which we may have to be aware of: Need Details: Language Cultural Access Travel
Which service you would like to access? Your Details: Name: Date of Birth: DD / MM / YYYY Address: Male □ Female □ Post Code: NHS Number: You will find you NHS number on: a medical card a letter from your GP or a hospital a printed prescription How we contact you? Landline Number: We will try to contact you by telephone unless otherwise advised. If possible, please provide a mobile number in addition to a landline. Mobile Number: Email Address: Please tick (a), (b), (c) if you do not give permission. a message with someone answering my phone □ leave a message on my answering machine □ send reminders via text message to your mobile □ Your GP’s Details GP Name: To find your GP address go to Practice Address: Postcode: Practice Tel No: We are required to notify your GP that you are accessing our service. Please provide permission for us to write to your GP with this information. Please note that if you do not give permission we are unable to offer you this service. I give Self Help Services permission to contact my GP. Yes □ No □ About You
Referral Form for The Sanctuary The Sanctuary is unable to accept those who have: 1) intoxication causing incoherence/ lack of cooperation and /or aggressive behaviour 2) self harmed at this time (rather than just thinking of self harming) 3) pose a risk of harm to others/ are behaving aggressively 3) made a current attempt to end their life or have expressed plans to imminently Date and time of referral contact call: Referral made to (site): Name of referrer: Role: Agency/organisation: Client Details First name: Surname: Date of Birth: DD / MM / YYYY Gender: Address Contact number: Home: Mobile: Please delete as appropriate: Consent to contacted by letter YES / NO any further contact Consent to be contacted by phone YES / NO Consent for voicemails to be left YES / NO Consent to be contacted by text YES / NO GP name & practice: The Sanctuary is accessed entirely voluntarily. Referrals will not be accepted without client consent. Has the client consent for this referral? Yes No NWAS ONLY Has an ambulance crew conducted a medical assessment with the client? (report to be submitted on arrival) Yes No GMP/BTP ONLY
Referrer Information Agency Name Worker Name Date: Agency Address Postcode Telephone Fax Email Why are you referring the client? (tick all that apply) Treatment: 1:1 Psychosocial Interventions Opiate substitute prescribing Group Programme Alcohol Opiate detox Residential treatment Relapse Prevention Counselling Reintegration TBC as part of assessment Advice: Harm minimisation and Advice Pregnancy related Weight loss Blood Pressure Medication Social factors Other (please specify below) Family & Friends support Unknown/To be confirmed as part of assessment Client Type: Criminal Justice Transitional ages Healthier lifestyle Alcohol / Opiate dependent Recreational user Dual Diagnosis MAST Hidden Harm Traveller/ Gypsy community Orbit only Please provide details of substances used, including frequency and route if known. Reason for referral: Service User Information Service User Name Date of Birth Address Mobile no Gender Male Female Audit C Score: if known /applicable’ Is an Interpreter needed? Yes No If yes, please specify language GP Name & Address Is the client prescribed medication? Please provide details Is the client homeless? Yes No Has the client given consent for the referral? Yes No Client signature: Risk Please provide details of any risks known at the point of referral (including mental / physical health, vulnerability, etc)) Safeguarding children: Please provide details of service users’ children Is the client parent to child under 18 or has contact with children under 18? Yes No Name DOB Gender M/F Address Contact Arrangements CP / CIN / LAC / TAF / etc?
Referral Form – Wellbeing Exeter Referrals can be made by telephone to 01392 823690 Alternatively email Introductions to Wellbeing Exeter can only be made by GPs for people aged 18 or over who are registered with participating Practices The following must be completed in order for us to work with your patient. Patient Details Has the patient or their appointed representative given consent for their details to be shared with Wellbeing Exeter? Yes No NHS Number: Please note we cannot accept a referral without this number <NHS number> Patient Address: <Patient Address> Date of Birth: (dd/mm/yy) Please note that only patients aged 18 and over can be referred to this service: <Date of Postcode: <Patient Address> Name of Patient: <Patient Name> Patient Contact Details: Home Tel: <Patient Contact Details> Mobile: <Patient Contact Details> Email: <Patient Contact Details> Gender: <Gender> Referrers Details Name of person making referral: <Sender Name> Referrers contact details: <Sender Details> Role and of work: <Sender Details> Date referral made to Wellbeing Exeter: <Today's date> Patient’s GP & GP Practice: <Organisation Address> Referral Please tick all that apply Does the patient have any sensory or communication issues? Social Practical Are there any risks we should be aware of (e.g. for lone workers)? Physical Emotional Does the patient have a carer? Please give brief details overleaf. Or are they a carer themselves?
Reason for referral: Please give brief details of your reasons for referring this patient. What will happen next? The patient will be contacted by a Wellbeing Exeter Community Connector and an arrangement will be made to meet with them. The meeting will take the form of a guided conversation through which the connector and individual will jointly determine areas with which the individual would like support. The connector will then implement the support as agreed with the individual and will follow up at regular intervals. Feedback will be given to the GP when the individual decides they no longer want/need support from their connector. Wellbeing Exeter office use only: Date inputted to database: Unique ID Number: Referral received via: Email Database Reference Number: Phone Fax – please give details Referral allocated to:
Resource for London, 356 Holloway Road London N7 6PA Tel 0207 697 4120 Fax 0207 697 4272 Email vanna@hibiscus.org.uk www.hibiscusinitiatives.org.uk Client Referral Form – Please return completed form via email to: , , you can also post a completed form to the address above FAO: Vanna or Anta Please note that we work with low to medium risk offenders and ex-offenders INFORMATION ON REFERRING ORGANISATION / AGENCY Date of referral: Has the client agreed to this referral? YES NO Name: Organisation: Contact no: Email: Relationship to client: CLIENT’S PERSONAL DETAILS Surname: First name: Date of birth: Prison No. if relevant: Release date: Address including Prison address if relevant: Can we write to the client at this address: Yes No : Land line: Email: Preferred method of contact: Offence history if relevant and sentence length: Previous convictions Yes No If Yes please specify: MG16 Yes No NATIONALITY, LANGUAGE AND IMMIGRATION STATUS Nationality: Country of origin: First language: Need for interpreter?: Yes No Can the client read/write in English? Yes No Are there any literacy issues? Yes No How long has the client lived in the UK? Please specify entry date if possible What is the client’s current immigration status? □ EU citizen □ Overstayer
Reason/s for Referral Wellbeing and Mental Health ⎕ General or Sexual Health ⎕ Alcohol and other Drugs Work, School, Study ⎕Other Please specify: Main issue/s: Relevant past history: Does the person currently see any other services: YES ⎕ NO ⎕ If yes, please tick appropriate box/boxes: Drug and Alcohol ⎕ School/Other Counsellor ⎕ Youth Justice/Juvenile Justice(VIC & NSW) ⎕ Community Services ⎕ Adult Mental Health ⎕ CAMHS/NECAMHS ⎕ Child Protection ⎕ Other ⎕ Service: Does the young person have a regular GP? YES ⎕ NO ⎕ If yes, please provide details below: Name of GP: Contact Details: Name of Service Provider: Phone: Is the other service aware of the referral to headspace? YES ⎕ NO ⎕ Will the services involved continue working with the young person? YES ⎕ NO ⎕ What are your expectations of headspace Albury Wodonga? Details of Referrer Name of referrer: Organisation: Relationship to young person: Address: Suburb: Postcode: Phone (business hours): Phone (mobile): Email:
SUPPORT NEEDS GIVE Budgeting (Managing money, debts, shopping) LOW MEDIUM HIGH Benefits (Claiming and applying) LOW MEDIUM HIGH Preparing & cooking LOW MEDIUM HIGH Home Management (keeping home clean & tidy, general household tasks) LOW MEDIUM HIGH Dealing with agencies LOW MEDIUM HIGH Training, Further Education & Employment LOW MEDIUM HIGH Keeping Appointments LOW MEDIUM HIGH Literacy Skills / Educational needs LOW MEDIUM HIGH Making friends LOW MEDIUM HIGH Parenting LOW MEDIUM HIGH Other: LOW MEDIUM HIGH Other: LOW MEDIUM HIGH
REFERRAL TO LIFEHOUSE RAPID ACCESS ENDOSCOPY SERVICE Rapid Access Endoscopy Service Chris O’Brien Lifehouse PO Box M33 Missenden Road NSW 2050 Email: Tel: +61 2 8514 1399 Fax: +61 2 9383 1074 REFERRAL TO PERIOD OF REFERRAL Dr Crispin Corte Dr Sean Griffin Dr Scott Davison 12 months Dr Kirk Austin Prof Christopher Young Dr Jonathon Hong Indefinite Dr Payal Saxena Dr Arthur Kaffes Dr Joshua Tang Dr Peter Lee Prof Chris Byrne Dr Justine Mill Dr Emilia Prakoso Dr Cherry Koh First Available Prof Michael Solomon Dr Darren Pavey PROCEDURE REQUESTED Gastroscopy Colonoscopy Gastroscopy + Colonoscopy Consultation prior to endoscopy INDICATIONS Rectal bleeding Family history of malignancies / polyps FOBT Cancer screening Polyp follow up Cancer exclusion cancer screening program Iron deficiency Other notes: PATIENT DETAILS Surname Given Names Date of Birth Address Contact Phone Numbers Home: Work: Mobile: REFERRER DETAILS Name: Provider Number: Address: (or stamp) Signature: Phone: Fax: Email: Date: Please email completed form to
Complete Form and Fax to 49236415 Belmont Midwifery Group Practice Birth Centre Team Midwifery Group Practice Centre Team Clinic Days (Thursday at Wallsend) Medical Record Number: Date of Referral: Name: Date of Birth: Address: Home Phone: Mobile: Email Address: Due Date: Gravida: Para: GP: Address: Place of Birth: Home Belmont Birthing Services JHH Birth Centre Student Midwife Yes No To be attended by Manager: Midwife Allocated: Date of Allocation
Dakota County Referral to Family Health Home Visiting Fax to 651-554-6130 or Email referral to Referral Source/Phone: Date: Name of clients/family members being referred Birth Date Sex Race/ Ethnicity Referral Reason name: M Initial Last name: M F PG, EDD: Postpartum Low Birth Weight Premature Other: M F PG, EDD: Postpartum Low Birth Weight Premature Other: M F PG, EDD: Postpartum Low Birth Weight Premature Other: M F PG, EDD: Postpartum Low Birth Weight Premature Other: Foster Parent/ Guardian Name (if not the parent): Family Address: Phone: cell home Alternate Phone: cell home Client may be contacted by: Phone Text Cell Phone Carrier E-mail We may leave Recorded message Message with person Client / family aware of referral: Y N Language: English Spanish Other: Interpreter Needed Y N First time parent: Y N Comments: Intake staff processing only: MA/Minnesota Care PMAP Private Insurance Client Insurance Information yes no PMI # PMAP # UCare BCBS HealthPartners Carrier: ID: yes no PMI # PMAP # BCBS HealthPartners Carrier: ID: yes no PMI # PMAP # UCare BCBS HealthPartners Carrier: ID: yes no PMI # PMAP # UCare BCBS HealthPartners Carrier: ID: Open to other Dakota County Programs yes no E&EA PH SS:(worker name) Mother Primary/Reason AP Par PP2WK PP3MO MVS-I MVS-C Other: Child Primary/Reason GRW ASTH BDIS EHDI LEAD FAP MVS-I MVS-C Other: Referral Destination: NSC Family Health WSC Family Health NSC FH Rapid Response WSC FH Rapid Response Child Passenger Safety PH Doc #: Pending: Intake PHN:
Involvement with other projects/ provision (Please give details you feel are relevant) Form completed by Name: Organisation Name: Date Relationship to young person Contact Number If you have any queries please contact Your Ideas Youth and Community Project: Your Ideas Youth and Community Centre, Dilwyn Close, Matchborough East, Redditch, Worcestershire, B98 0BU Tel: 01527 502624 Email: Pauline Marshall: Jordan Cooke: jordan.cooke@yourideas.org.uk
UNION Send Clinical Services Referral to: Alice Alexander, PhD 732-424-3303 Send Clinical Services Referral to: Jonathan Seifried 609-689-1786 Jonathan.Seifried@dhs.state.nj.us Send Clinical Services Referral to: Alice Alexander, PhD 732-424-3303 Send email/request to: Esther McCarthy 908-412-7746 Esther.McCarthy@dhs.state.nj.us Barbara Campbell 908-412-7743 WARREN Send Clinical Services Referral to: Andrew McNulty, PsyD 973-927-2686 Andrew.mcnulty@dhs.state.nj.us Send Clinical Services Referral to: Jonathan Seifried 609-689-1786 Jonathan.Seifried@dhs.state.nj.us Send Clinical Services Referral to: Andrew McNulty, PsyD 973-927-2686 Andrew.mcnulty@dhs.state.nj.us Send email/request to: Hughretta Walker 973-977-4004 Hughretta.Walker@dhs.state.nj.us Dustin DiCristo 973-977-4004 Anne 973-977-4004 Anne.Lacey@dhs.state.nj.us
Under 8 years: sh said as “t” or “s”, ch said as “t”, “s” or “sh” j said as “d”, “z” r said as “w” y said as “w” or “l” th said as “f” the said as “v” Sounds Speaks down their nose. Has a history of food coming down their nose. Has a cleft lip or palate. Copies of this checklist are on our website:
Plagiarism Checker When you submit assignments/projects on your course they will be checked for plagiarism in line with Monaghan Institute’s plagiarism policy. If you have referenced correctly in your assignment then this should not cause any issues. If you have not referenced you work correctly using the Harvard System then you will forfeit marks for your work. You can test your assignments using an online plagiarism checker. Access the link below and follow the instructions given to check your work: * Refer to your student handbook for more information on Monaghan Institute’s plagiarism policy and related sanctions.
Dietetic Referral Form Please complete this form fully and return to: Nutrition & Dietetic Services, St Martin’s Hospital, Bath, BA2 5RP or email it to . Please note that this email address is for referrals only. If the referral is urgent please telephone the Dietetic Department on 01225 833916. Please note that incomplete forms may be returned. Patient Contact Details Title: Name: Address: Postcode: Tel no: Email Address: Mobile no: Does patient consent to message being left on answer phone? Y / N Does patient consent to email correspondence? Y / N Does patient consent to text message correspondence? Y / N Patient Details DoB: NHS no: Gender: M / F Ethnic group: GP and Next of Kin Details GP Name: GP Practice address: Postcode: Tel no: Next of Kin Name: Relationship to patient: Tel No: Are they the main carer? Y / N If no, does the patient have another carer? Y / N Please provide contact name and details: Medical Information- Clinical print out attached Y / N Diagnosis: Does patient have Diabetes? Y / N T1 / T2 Past Medical History: Social History: Relevant medications: Sip feeds: Relevant results: HbAlc Other results: Weight (kg): Height (m): BMI (kg/m²): Weight loss(in last 6 months): MUST score: (nutrition screening) Does the patient require a texture modified diet? Y / N Details: Does the patient have any food allergies or intolerances: Y / N Details: Other comments: Reason for Referral
To: North East Sensory Services 21 John Street Aberdeen BT (Office use only) Referral taken by: Date: Known to Ness: No. Yes: Last contact date: Allocated to Date CLIENT DETAILS: Name: Address: Post Code: Tel: Email: Date of Birth Lives alone: Yes ☐ No ☐ Ethnic origin: White: Asian: Mixed/multi ethnic: ☐ African/African Scottish/British ☐ Caribbean or Arab/Arab Scottish/British ☐ Arab other: ☐ Accommodation Home owner ☐ Local Authority ☐ Housing Association Care home ☐ Sheltered Housing ☐ ☐ Occupation: School attended: DETAILS RELATING TO SENSORY LOSS (click after colon for drop down list) Hearing category: Vision category: Communication Method: Hearing aid info: OTHER HEALTH ISSUES AND/OR CARE CURRENTLY RECEIVED. Emergency Contact GP:
Ideally what advice, support or service would you like us to provide? Thoughts and concerns of the young person: Professionals involved – please tell us of professionals who are currently supporting the child/family NOTE: If you are a professional completing this form please go to Part B Name Job Title: Organisation & Contact details: Part B. To be completed by professionals only Professional Referral If you are a professional making this referral please provide your details Name Job Title: Organisation: Address: Office Tel: Email: Mobile Tel: Are you currently actively supporting the young person/family? Yes No if Yes please give details: Reason for Referral: Other Professionals involved – please tell us of other professionals who are supporting the child/family Name Job Title: Organisation & Contact details: Part C. Signature and Date How did you hear about Autism Family Support Oxfordshire? (Please ‘X’ all that apply) From the diagnostic clinic School/college Someone who uses our service A talk/training CAMHS/PCAMHS Social Worker/Family Support Worker Online search Other:
Provider Choice Please tick your chosen provider Care Fertility - Nottingham Satellite Clinics located at Derby Fertility, Royal Derby Hospital, Boston, Pilgrim Hospital Peterborough John Webster House 6 Lawrence Drive Nottingham Business Park Nottingham NG8 6PZ Care Fertility - Northampton 67 The Avenue Cliftonville Northampton NN1 5BT Care Fertility - Sheffield 24-26 Glen Road Sheffield S7 1RA NUTURE The East Midlands Fertility Centre Satellite Clinic located at Burton Fertility Clinic Interchange 25 Business Park Bostocks Lane Sandiacre Nottingham NG10 5QG www..co.uk Oxford Fertility Centre Institute of Reproductive Sciences Oxford Business Park North Alec Issigonis Way Oxford OX4 2HW Cambridge IVF Cambridge University Hospitals NHS Foundation Trust Kefford House Maris Lane Trumpington Cambridge CB2 9LG t. 01223 349010 Secure address for referrals: Sheffield Teaching Hospitals Jessops Fertility Unit The Jessop Wing Tree Root Walk Sheffield S10 2SF
CHELTENHAM & TEWKESBURY ALTERNATIVE PROVISION SCHOOL REFERRAL FORM – PRIMARY & OUTREACH ALL SECTIONS TO BE COMPLETED BEFORE SUBMITTING TO Start Date (office use only) UPN GENDER MALE/FEMALE ULN Pupil’s Name DOB YEAR GROUP Parent(s)/ Carer(s) PARENTAL YES/NO ETHNICITY FIRST LANGUAGE RELIGION Address C.I.C (If Yes please give date) YES / NO PUPIL PREMIUM YES / NO SERVICE FAMILY YES / NO Telephone No MY PLAN + EHCP PENDING REVIEW DATE PRIMARY NEED EHCP DATE ISSUED PRIMARY NEED MULTI-AGENCY WORKING AND SUPPORTING DOCUMENTS
AGENCY / SERVICE INVOLVED NAME OF PROFESSIONAL CONTACT DETAILS DOCUMENTS / REPORTS ATTACHED? BASELINE DATA CURRENT LEVELS ENGLISH PREDICTED LEVELS AT END OF KEY STAGE ENGLISH ATTENDANCE % THIS ACADEMIC YEAR PRESENT MATHS MATHS AUTHORISED SCIENCE SCIENCE HOW MANY DAYS OF EXCLUSION HAS THIS PUPIL HAD THIS YEAR? CATS VRQ VERBAL NON VERBAL QUANTITIVE MEAN SAS WHY ARE YOU REFERRING THIS PUPIL TO THE APS? WHAT ARE YOU HOPING FOR AS AN OUTCOME OF THIS SUPPORT FOR THIS PUPIL? INFORMATION GATHERING PUPIL STRENGTHS: PUPIL STRENGTHS:
Patient details & demographics Title Dr Miss Mrs Mr Ms Prof Rev Surname Forename(s) Maiden name (if any) Previous surname(s) Home address Telephone number Mobile number (if any) Emergency contact name (next of kin) Relationship to patient NoK contact number NoK email address NoK address Gender Date of birth Marital status Nationality Ethnic origin Indian Pakistani Bangladeshi Other Asian background White & Black Caribbean White and Asian Other mixed background Chinese ethnic group Caribbean African Black background White Irish Other White background
Whittlesea Connect Community Transport Service Agency Referral Form Access to the service is by referral only. This form must be completed by a Doctor or Nurse, community, health/welfare, social services worker or family member. (Please read Whittlesea Community Transport Service brochure when filling in referral) Please see community transport brochure for details about the service: REFERRAL DETAILS Date: ___/___/______ NEW CLIENT or  EXISTING CLIENT : ____________ Active Inactive/discharge date: ___/___/____ CLIENT DETAILS MELWAY REF: Family Name: ___________________ Given Name: __________________ Preferred Name: _______________ Sex: Male Female Title: Mr Mrs Ms Miss Other (Please specify ): ___________________ Date of Birth: ___/___/____ is the client registered with DHS? Yes No Has DSR? Yes No Not sure Address: _______________________________ Phone Number: _____________ Mobile: __________________
REFERRAL PROCESS: Werribee HIP STEP 1 STEP 2 STEP 3 Essential referral content will be checked. You will be contacted if further information is required. Acknowledgement of referral receipt will occur within 24-48 hours. The Werribee HIP Access Unit will triage the referral according to clinical need. This determines how long the client will have to wait for an appointment. Clients will be contacted within 5 business days of receipt of referral GP will be notified of involvement of HIP. REFERRAL PROCESS: Werribee HIP The clinical information provided in your referral will determine the triage category. The triage category will affect the timeframe in the client is offered an appointment. Community Based Rehabilitation (CBR) Eligibility Criteria Community Rehabilitation (CBR) offers multidisciplinary assessment and treatment to clients over the age of 16 who are disabled, frail, chronically ill or recovering from surgery or traumatic injury, to achieve and retain the best function possible. It is time limited and does not offer maintenance therapy or case Over 16yrs of age Achievable rehab goals Medically stable
415-239-1700 Condo conversion – Evan Donaldson, Diverse Inspections, 415.665.8288 Drywall Carlos Olguin (also a painter), 415-505-9899, Tony’s Drywall, (650) 754-1076 Electrician TC Electric, 415-431-2699 A&S Electric, (415) 877-0116 Energy Inspector Paul O'Connor, City-Wide Insulation Co. Energy Inspections (415) 652-0260 Escrow Officer Charles Richards, Chicago Title 415-252-2754 Exterminator X-pest Exterminator, Financial Advisor Jane Wang, Merrill Lynch Wealth Management, 415-955-3746 Floors Steven’s Hardwood Floors, M & J Floor Specialist, Nelson Vu, 415-308-3721 B & V Flooring, Victor Dudakov 415-350-0731, Furnace/Heating Apollo Heating, Manny 415-585-3635 Annuzzi Heating and Cooling, Saverio, 650-552-9885, Garages and Garage SF Garage, John Pollard, Bay Area Garage Doors, John and Dave, 415 282 7277 Garage Doors/openers – Herb Kritz, 415-931-1540 Gardener/Hauler Martin Moncada, 650-834-5280 work, 650-997-3584 home Jeffrey Paul, Glass Sunset Glass, (415) 664-1626 Granite and Installation Benattar Granite and Marble, Raul Contreras, (415) 285-5995 Gutter Cleaners David Sanchez, 415-706-5887 Manuel Franco, 415-722-5698 Handymen Jake Wrench, (415) 641-0955 Lorenzo, 415-532-5992 Paul Woodford, (415) 282-9522 Hardware for Cabinets EM Hundley Hardware, (415) 617 Bryant St. Hauler Hassle Free Hauling, Dan Mahoney, 415-468-3713 Home Insurance Craig Dellinges, Farmer’s Insurance, 415-333-7272 Interior Designers Lars Von Lowen, lars@vonlowendesigns.com Kitchen cabinets Home Depot, Colma, PC Kitchens, Helen Wong, Landscapers Tilden Landscaping, David Cummings, (415) 260-9720 Mariposa Gardening and Design, 510-588-8429, 415-
Assessment Data including (social and emotional) 2c. Pupil Assessment and Tracking (EYFS ONLY) Area of learning and development Aspect Age Age Age Anticipated age band at end of school year Date Date Date For each Aspect please indicate Emerging Developing or Secure within age band (0-11 8-20 16-26 22-36 30-50 40-60+ months) Personal, Social & Emotional Development Making relationships Self-confidence & Managing feelings and behaviour Communication & Language Listening & attention Understanding Speaking Physical Development Moving & Handling Health & self-care
Name of Social Worker Address of Social Worker Authority (if not Buckinghamshire) Telephone Foster Carer Surname First Names (in full) Title Foster Carer Surname First Names (in full) Attached is Social Care, Children & Families agreement to request for EHC Assessment tick 1e. Are there any reasons why it may not be appropriate to visit the family home? Y / N SECTION 2: Areas of need 2a. How would you summarise the child / young person’s area(s) of need? Evidence of need and support provided must be included with submission. AREA OF S.E.N. CATEGORIES OF SEN Please refer to SEN Code of Practice (2014) Primary Need Tick ONE only Additional Needs Cognition & Learning Specific Learning Difficulties Moderate Learning Difficulties Severe Learning Difficulties Profound and Multiple Learning Difficulties Communication & Interaction Speech Language and Communication Autistic Spectrum Disorder
Integrating Children Referral Process Part One 1. Referral Process 2 2. Priority Assessment Tool 5 3. Letter 1 – Enquiry Form letter 7 4. Enquiry Form 9 5. Letter 2a – Acknowledgement High / Medium 11 6. Letter 2b – Acknowledgement Decline 12 7. Letter 2c – Acknowledgement Low Priority 13 8. Letter 3 – Activity Sheet letter 14 8. Activity (to follow) 15 9. Letter 4 – Welcome 16 Part Two 10. Process for dealing with outstanding referrals 17 11. Existing Waiting List letter 18 12. Email for enquiries through Children’s Network 20 Annexes Annex A Durham County Council description of disability 21 Annex B Integrating Children Referral Catchment Area 22 Annex C Other Universal Short Break Providers in 22 Integrating Children Referral Process Referral Process
Integrating Children – Priority Assessment tool Priority Feature Yes No Score Comment Initial score 6 Start assessment with score of 6 1. Is the child between 5 and 18 Go to 2 Not eligible We do not hold younger children on the waiting list. Referrals can only be accepted from children within age range. If over 18 see adult referral process 2. Has child a disability as defined by Children’s Network Go to 3 Not eligible See Annex A 3. Does normally live in the old County districts of Durham City or Chester le Street Go to 5 Go to 4 The previous criteria of able to travel to Durham or CleSt has changed as there are now services in each of the old districts. See Annex B. 4. Is there a compelling reason why the child should attend IC even though they live outside the area (must live in Co Durham or ineligible) Go to 5 Not eligible This would include such things as parent working in Durham / Chester over weekends or regular stays with relatives in area. 5. Does child attend other funded activity, including through Direct Payment or Short Break elsewhere. 1 other activity a week More than 1 activity a week Subtract from score – 1 2 Go to 6 DCC requires IC to spread Short Break services and exclude children attending other services until all on waiting list are provided for. 6. Does the child attend residential or overnight short break Go to 7
Please add any additional information regarding areas of potential harm to referred person or others. Area of potential harm (Outline what cause harm or damage) Who might be harmed Existing Control Measures Risk Rating (Please refer to Page 1) Warning Signs Triggers Further Actions Required OR Additional Comments
Excellent 70%-100% Good 60%-69% Satisfactory 50%-59% Poor 40%-49% Very Poor 0%-39% Presentation (0-8) 6-8 5 4 3 0-3 Coverage (0-10) 7-10 6-7 5-6 4-5 0-4 Sources (0-12) 8-12 7-8 6-7 5-6 0-5 Knowledge and understanding (0-20) 14-20 12-14 10-12 8-10 0-8 Critical evaluation (0-24) 17-24 14-17 12-14 10-12 0-9 Evidence and coherent argument (0-26) 18-26 16-18 13-16 10-13 0-10 Total mark as percentage % 3.4 Exam Assessment Marking Criteria Excellent 70%-100% Good 60%-69% Satisfactory 50%-59% Poor 40%-49% Very Poor 0%-39% Presentation (0-5) 5 4 3 2 0-1 Coverage (0-8) 6-8 5–6 4 3 0-3 Sources (0-10) 7-10 6-7 5-6 4-5 0-4 Knowledge and understanding (0-22) 15-22 13-15 11-12 9-11 0-9 Critical evaluation (0-26) 18-26 15-18 13-15 10-13 0-10 Evidence and coherent argument (0-29) 19-29 17-19 14-17 12-14 0-12 Total mark as percentage % 4. References The terms references and bibliography are used to refer to sources that are consulted for the writing of an assignment, but they have different meanings. The term reference refers to works which are directly cited in the assignment. The term bibliography refers to works which a student has drawn upon to write an assignment whether or not they are directly cited. Thus, a bibliography can be said to include references but not vice versa. Bibliography is sometimes used in a narrower sense to exclude references. Where books have shaped your understanding of a topic, you are urged to acknowledge directly that contribution and to treat them as references. In your written work, tutors will expect you to demonstrate evidence of wide and critical reading. There are various systems of referring to the works which you have read and are quoted in your essays.
Email: 49 Dr Aggarwal Eye Hoapital Block-1, BMC Bhabani Mal Saheed Nagar, Bhubaneswar. Eye Mob: 8118052201 50 Manipal Hospital, 98, HAL Airport Road, Bengaluru-560017 General medicine,cardiology, Oncology, cardio thoracic & vascular surgery,Nephrology, Orthopedics & Joint replacement, and Urology Ph. no 8105694214 Contact person-Asutosh Pattnaik
13Other storages on the same premises that are not part of this application: (Tick all that apply) Diesel Oxygen Gasolene Jet A1 Crude Oil/ Condensate/NGL NA 14Buildings on the same premises are: (Tick all that apply) Residential Commercial Agricultural Public Assemblage Industrial Government Parking/ storage (specify below) 15Is the area to flooding? Yes No 16Has the area City/Regional/ Borough Corporation been advised of the installation? Yes No 30Is your company registered and approved by the Ministry of Energy & Energy Affairs for the purchasing of subsidised diesel fuel? Yes No NA If yes, state registration number and/ or date of application: Section D : Piping Information 1Hydrocarbon piping is located: (tick all that apply) Aboveground Outdoor Underground Indoor 2Hydrocarbon piping material of construction: aAboveground bUnderground 3Type of hydrocarbon piping joints: (tick all that Threaded Welded Flanged Brazed (specify below) 4Minimum depth of hydrocarbon underground piping: NA Value e.g. 3.5 Unit e.g. ft. (click to choose) 5Type of corrosion protection for underground piping: NA 6Underground piping is Yes No NA If yes, material of construction of outer wall: Section E: Tanks Information Provide the listed information for each tank For additional tanks, use the supplemental form. Tank 1 Tank 2 Tank 3 1Product to be stored in tank: (click to choose e.g. diesel) If other, specify below: If other, specify below: If other, specify below: 2Operational status of tank: (click to choose e.g. currently in use) 3Tank is located: (Tick all that Aboveground Underground Aboveground Underground Aboveground Underground Indoor Outdoor Indoor Outdoor Indoor Outdoor Roof Basement Roof Basement Roof Basement Warehouse Internal day tank Warehouse Internal day tank Warehouse Internal day tank Mounded Other Mounded Other Mounded Other If other specify below: If other specify below: If other specify below: 4Tank is: (Tick all that Fixed Mobile Fixed Mobile Fixed Mobile
(click to choose unit) 25aType of secondary containment Double-wall tank Bund Double-wall tank Bund Double-wall tank Bund Drain & Pit None Drain & Pit None Drain & Pit None 25bIf double-walled tank, material of construction of outer shell e.g. steel: 25cIf double-walled tank, means on interstitial space leak detection e.g. sensor: (click to choose) If other specify below: If other specify below: If other specify below: 25dIf bunded, are all tanks in the same bund? Yes No If yes, dimensions of bund: Length: e.g. 20 Unit e.g. in. e.g. 20 Unit e.g. in. Height: Value e.g. 20 Unit e.g. in. 25eIf tanks are not in the same bund, dimensions of individual tank bund: Length: Value e.g. 20 Unit e.g. in. Length: Value e.g. 20 Unit e.g. in. Length: Value e.g. 20 Unit e.g. in. Width: Value e.g. 20 Unit e.g. in. Width: e.g. 20 Unit e.g. in. Width: Value e.g. 20 Unit e.g. in. Height: Value e.g. 20 Unit e.g. in. Height: Value e.g. 20 Unit e.g. in. Height: e.g. 20 Unit e.g. in. 26Material of construction of bund wall: 27Minimum (shell to shell) spacing between tanks? e.g. 20 Unit e.g. in. Not applicable …End of Supplemental Form…