Outside Agency Referral

*

1. Question 1.

Verbal Consent obtained to refer to PCGS?

Required - Required.

Yes

No

*

2. Question 2.

Name of referrer?

Required - Required.

Name

Organisation

Email address

Contact number

*

3. Question 3.

Patient Demographics?

Required - Required.

Client ID

Title

Forenames

Surname

Date of Birth

Address

Postcode

Email address

Telephone number

Consent to text

Consent to leave voicemail

Consent to email

*

4. Question 4.

Ethnicity

Required - Required.

White

British

Irish

Other

Asian or Asian British

Indian

Pakistani

Bangladeshi

Any other Asian background

Mixed

White and Black Caribbean

White and black African

White and Asian

Any other mixed background

Black or Black British

Caribbean

African

Any other black background

Other Ethnic Group

Chinese

Any other Ethnic Group

I do not wish to disclose my ethnic origin

*

5. Question 5.

Reason for referral?

Required - Required.

6. Question 6.

Please state what treatment the patient has had with your service

7. Question 7.

Next of Kin consent to contact in an emergency.

Yes

No

8. Question 8.

Next of Kin details to contact in an emergency?

Relationship

Name

Contact

*

9. Question 9.

Consent to contact GP?

Required - Required.

Yes

No

10. Question 10.

GP Contact Details.

11. Question 11.

Any other relevant information.

12. Question 12.

Is the patient an affected other?

Yes

No

13. Question 13.

Please attach assessments here if applicable

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Comments:

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14. Question 14.

What is the best time of day to contact you, to book your assessment.