Icebreak Referral Form Referral date:______________

Full Name: Date of Birth: Age:

Have you ever been or are now known by anoth-er name?

Yes No

Please state:

Address:

Postcode: Gender:

Contact Number (s): Email:

Do you consent to being sent SMS communication? (including appointment reminders)

Yes No

Preferred method of contact:

Agency / Service name/ Name of worker Approx. date started

Approx. date finished

Past Cur-rent

Other Agencies

Please note down any other agencies / services you have worked with in the past, or are currently working with such as mental health services, Social Services, accommodation support, community and support within educational settings.

Referred/signposted by?

Role:

Address:

Contact No: Email:

GP Name: Surgery Name:

Next of Kin: Contact Number:

Address: Relationship:

Office use only

A

Do you have any dependants?

If ‘yes’, please provide details below Yes No

Please let us know your main reasons for making this referral (please note that it is essential that you fill this sec-tion in): e.g. what are your current main struggles or issues?

Reason for Referral

Suicidal Behaviours and Self-Harm

There may be times in a person’s life when they become very low and may feel like taking drastic action:

Have you ever made an attempt to take your life? Yes No

If yes, when did this happen?

If ‘yes’, please provide details:

Have you ever harmed yourself without intending to kill yourself?

Yes No

If ‘yes’, when did this happen?

If ‘yes’, please provide details:

Relationships and Family

Please provide some information about your current close relationships, including support networks (e.g. family, partner, friends, colleagues)

MSI-BPD

Yes No

Have any of your closest relationships been troubled by a lot of arguments or repeated breakups?

Have you deliberately hurt yourself physically (e.g., punched yourself, cut your-self, burned yourself)? How about made a suicide attempt?

Have you had at least two other problems with impulsivity (e.g., eating binges and spending sprees, drinking too much and verbal outbursts)?

Have you been extremely moody?

Have you felt very angry a lot of the time? How about often acted in an angry or sarcastic manner?

Have you often been distrustful of other people?

Have you frequently felt unreal or as if things around you were unreal?

Have you chronically felt empty?

Have you often felt that you had no idea of who you are or that you have no identity?

Have you made desperate efforts to avoid feeling abandoned or being abandoned (e.g., repeatedly called someone to reassure yourself that he or she still cared, begged them not to leave you, clung to them physically)?

Life Experiences

Have you experienced any of the following:

Currently Experiencing

Never Experienced

Have Experienced

Experienced an unstable home/ family life

Experienced being in care

Experienced physical abuse

Experienced sexual abuse

Experienced sexual assault

Experienced domestic abuse

Experienced emotional abuse

Experienced discrimination

Please provide further information about these if relevant:

Seeing Visions / Hearing Voices

Have you ever heard a voice that others could not hear? Yes No

Have you seen something that others could not see? Yes No

Please provide a brief description about these if relevant:

Smoking, Substance and Alcohol Use

Substance/alcohol

Social Stop think-ing,

calming down

Help to

sleep

Cope with pain

Forget, block out

visions

Feel less anx-ious

Feel less

angry/agitat-

ed

Boost confi-dence

Frequency of use (e.g daily/weekly/monthly)

Quanti-ty

Please list any substances or alcohol use, tick the relevant boxes for the reasons you use them

Are you a smoker? Yes No How many cigarettes do you smoke on average a day?

Would you like support to reduce or stop any of the above?

Yes No If ‘yes’ please state:

Criminal Court and Family Court Activities

Activity Date Outcome

Please list any previous or current legal proceedings including child care.

Are there any other negative behaviours that you take part in?

Yes No If ‘yes’, please provide details:

Other Behaviours

CORE 34 Outcome Measure

Please identify up to 3 goals you would like to work towards. How would you like things to be different?

1

2

3

Goals

Office use only

Mobility impairment Hearing impairment

Sight impairment Learning difficulty

Chronic illness Physical health condition

Other (please state:)

If you have answered ‘yes’ to any of the above, please give details:

Do you consider yourself to have a disability?

Yes

If you have answered yes, please tick the relevant boxes.

No

Equality, Diversity and Accessibility

Diagnosis

Do you have any sensitivities and/or allergies?

Yes No

Please provide details:

Sensitivities and Allergies

Do you have any current diagnoses?

Yes No

Please provide details:

Please write down any medication that you are currently prescribed and the dose that you are prescribed

Medication

Medication Date started Dose

Sexual Orientation

How would you best describe your sexual orientation?

Prefer not to say Straight

Gay Lesbian

Bi-sexual Pan-Sexual

A-Sexual Other (please state)

Ethnicity

White

British Any other White background

Irish Please state:

Mixed

White and Black Caribbean

White and Black African

White and Asian Any other Mixed background

Asian or Asian British

Indian Pakistani

Bangladeshi Any other Asian background

Black or Black British

Caribbean African

Any other Black background

Chinese Chinese

Any other ethnic group (please specify)

Religion

How would you best describe your religious beliefs?

No religion Christian (including Church of England, Catholic,

Protestant

Buddhist Hindu

Jewish Muslim

Sikh Prefer not to say

Other Please specify:

Accommodation

Which statement best describes your current living situation:

Own your own property Renting a property privately

Social housing Living with parents/family (or alternative caregiver)

Student accommodation Living in bed and breakfast/ hotel accommodation

Living in supported accommodation

Living in a hostel

Sofa surfing/staying with friends

Sleeping rough

Other Please specify:

Please write down anything you would like to add about your living situation (e.g. what is the reason for you living there):

Are you satisfied with living here? Yes No

Employment Status

Please tick the box next to the statement which best describes your current work situation.

Paid employment

If ‘yes’ what is your job?

Number of hours per week:

Long term sick and in receipt of benefits If ‘yes’, what benefits are you in receipt of?

Unemployed and seeking work

Unpaid voluntary work and not looking for paid employment

Homemaker looking after family or home and not seeking work

Student If ‘yes’ where are you studying? What course are you studying? When did your course start?

Other. Please state:

Education and Training

Please tick the box next to any level of educational achievement:

GCSE A Level

NVQ / GNVQ or equivalent BSc / BA

MSc / MA Other Please state:

Please give details of times and days that are best suited to you for appointments. We will try and accommodate these times the best that we can although this can be difficult at times.

Have you ever served in the

Armed Forces?

Yes No

If ‘yes’, please provide details:

Availability

Important Information Included in this referral pack is a number of leaflets relevant to important questions and consent that we must ask you as well as other information that is applicable to a referral to Icebreak being made. Please take the time to read the leaflets and answer the questions below. Please feel free to remove these leaflets and retain them for your information.

By submitting this referral form I understand that I am consenting to engaging with Icebreak and understand the information provided to me within this referral pack.

Name…………………………………………………………Signature……………………………………….. Date……………..…..

Sharing Electronic Information Please read the attached information leaflet about your electronic record and complete the questions below. Sharing Out – Do you consent to the sharing of data recorded by Icebreak with other NHS organisations that may care for you?

YES share data with other NHS organisations NO do NOT share any data recorded by Icebreak; I fully accept the risks associated with this decision

Sharing In – Do you consent to Icebreak viewing data that is recorded at other NHS organisations and care services that may care for you?

Summary Care Record Please read the attached information leaflet about your Summary Care Record (SCR) and complete the questions below. Do you consent to Icebreak having access to your Summary Care Record?

Name…………………………………………………………Signature……………………………………….. Date……………..…..

You can choose to have additional information included in your SCR, which can enhance the care you receive. This information includes: • Your illnesses and health problems • Operations and vaccinations you have had in the past • How you would like to be treated - such as where you would prefer to receive care • What support you might need • Who should be contacted for more information about you If you would like this information adding to your SCR, then please complete this form and we will send it to the rele-vant GP surgery. Name of Patient: ………………………………………………..…................................ Date of Birth……………………………. Patient’s Postcode: ………………………….…..…...……... Surgery Name: …………………………….…………….……..…..

Name…………………………………………………………Signature……………………………………….. Date……………..…..

Sharing Information with Others

Please list any people that you feel it would be helpful for Icebreak to share information with such as any family members or professionals that you are working along with and what sort of information you think would be helpful to share with them.

Yes No; I fully understand and accept the risks associated with this decision

Consent declined; I fully understand and accept the risks associated with this decision

Yes, share data with Icebreak from other NHS organisations

This le

afle

t will:

Pro

vide in

form

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Care Q

uality C

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missio

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Th

is w

ill m

ake

it e

asie

r fo

r o

ur

do

cto

rs,

nu

rses

an

d h

ea

lth

ca

re s

taff to

he

lp y

ou

ma

ke

de

cis

ion

s a

bou

t yo

ur

ca

re.

Systm

On

e is c

urr

en

tly u

se

d in

a v

arie

ty o

f

he

alth

ca

re s

ett

ings, fo

r e

xa

mp

le: G

P p

ractices,

ch

ild h

ea

lth

se

rvic

es,

co

mm

un

ity s

erv

ice

s,

ho

sp

ita

ls a

nd

ma

ny m

ore

.

Yo

u m

ay h

ave

op

ted

in o

r o

ut of

up

loa

din

g

yo

ur

info

rma

tio

n f

rom

yo

ur

GP

pra

ctice

. W

e

will

se

ek e

xp

licit c

on

sen

t to

se

e y

ou

r su

mm

ary

ca

re

Co

ns

en

t to

Sh

are

W

hen y

ou

are

first

or

ne

xt

se

en

at

the

ca

re

se

rvic

e,

yo

u w

ill b

e a

ske

d th

e fo

llow

ing

qu

estio

n:

Do

yo

u c

on

se

nt

to t

he

in

form

ati

on

rec

ord

ed

ab

ou

t yo

u h

ere

bein

g m

ad

e

ava

ila

ble

to

oth

er

NH

S s

erv

ice

s p

rovid

ing

yo

ur

ca

re?

YE

S -

th

is m

ean

s t

ha

t clin

icia

ns a

t o

the

r

he

alth

ca

re s

erv

ice

s t

ha

t u

se

Systm

On

e w

ill b

e

ab

le to

see

th

e info

rmatio

n r

eco

rde

d h

ere

. N

O -

oth

er

hea

lth

ca

re c

linic

ian

s w

ill n

ot

be

ab

le to

see

th

e info

rmatio

n w

e h

ave

re

co

rde

d.

Ho

w d

oes

th

is w

ork

?

Ex

am

ple

: Im

agin

e y

ou a

re r

ece

ivin

g c

are

fro

m

thre

e d

iffe

rent

NH

S s

erv

ice

s:

yo

ur

GP,

a

Dis

tric

t N

urs

e a

nd

a s

mo

kin

g c

linic

. Y

ou

wa

nt

yo

ur

GP

an

d n

urs

e to

sh

are

info

rma

tio

n w

ith

ea

ch

oth

er

and

yo

u w

an

t bo

th o

f th

em

to

know

yo

ur

pro

gre

ss a

t th

e s

mo

kin

g c

linic

. H

ow

eve

r,

yo

u d

on

’t w

an

t th

e s

mo

kin

g c

linic

to

see

an

y o

f

yo

ur

oth

er

me

dic

al in

form

ation

. Y

ou

r sh

arin

g s

ett

ings w

ou

ld b

e:

Ho

w w

ill yo

u c

on

tro

l w

ho

can

see m

y E

PR

?

An

yo

ne

wh

o h

as a

ccess t

o y

ou

r re

co

rd w

ill b

e:

• D

ire

ctly in

vo

lve

d in

yo

ur

ca

re a

nd

tre

atm

en

t

• A

ssig

ne

d a

se

cu

re a

cce

ss m

eth

od

th

at

ide

ntifie

s t

hem

• A

ble

to

see

on

ly t

he

info

rma

tio

n th

ey n

eed

to d

o t

he

ir jo

b

• T

racke

d f

or

eve

ry a

ctio

n t

he

y t

ake

on

th

e

syste

m

Ho

w w

ill yo

u p

rote

ct

my

co

nfi

de

nti

ali

ty?

•

We h

ave

a le

ga

l d

uty

to

pro

tect

yo

ur

co

nfide

ntia

lity a

nd k

eep

all

info

rma

tio

n

ab

ou

t yo

u s

ecu

re.

• E

mp

loye

es w

ho

are

not

dire

ctly in

vo

lve

d in

yo

ur

ca

re b

ut w

ho

ha

ve

acce

ss t

o th

e

ele

ctr

on

ic s

yste

m a

cro

ss a

ll d

ep

art

me

nts

are

exp

ecte

d to

ad

he

re t

o p

olic

y a

nd

co

de

s

of

pro

fessio

na

l con

du

ct.