SPLD Learning Disability Referral Form

Referral form to services for people who have a learning disability (SPLD) via the ELFT Specialist Healthcare Team.

Referral to services for people who have a learning disability (SPLD) - Specialist Healthcare Team

Eligibility criteria to access our service:

- Must be registered with a GP in Bedfordshire & Luton - Must be aged 18 years or over to receive direct clinical support (Referrals/ information for young people approaching 18 will be considered to support transition, from age 17) - Must have a learning disability, which prevents access to mainstream services - Must consent to this referral (please ensure that section on consent/ capacity/ best interests is fully completed) - Must agree to have their information shared where appropriate

Personal Details

Full Name

NHS number

Date of birth (DOB)

You can add your own date of birth.

Address

City/Town

ZIP/Postal Code

Interpreter required?

Yes

If yes, please state language

Please tick the best way to contact the service user

Telephone number

Mobile number

Telephone Number

Mobile number

Details of next of kin, or carer

First Name

Last Name

Address

City/Town

ZIP/Postal Code

Relationship

Telephone of next of kin

Mobile of next of kin

Email address of next of kin

Advocate/LPA/Court Appointed Guardian contact details (if applicable)

GP Details

First Name

Last Name

Address

City/Town

ZIP/Postal Code

GP telephone

GP email

Is this person on the GP Learning Disability register?

Yes

Do they receive an Annual Health Check?

Yes

What are your key diagnoses?

Current Medication/Allergies

Is there a documented diagnosis of learning disability? (If unsure please complete screening tool towards the end of referral)

Yes

Diagnosis:

Mild

Moderate

Severe

Profound

Not known

Other…

Which school did the person attend?

Do they have an Educational Health Care Plan (ECHP) in place?

Yes

If Yes, please provide copy with this referral

Reason for referral

What is the clinical need? (What’s happening that the service user needs help with? Is it around activities of daily living / sensory needs / communication / eating and drinking / eyes and ears / accessing Primary Care / Annual Health Checks / health prevention and health promotion / medication review / mobility / bereavement / behaviours / emotions / or support around mental health)

Detail clinical need here:

How long has this been an issue?

Has the service user tried mainstream services for this clinical need?

If you think you know which team/s you need support from, please tick appropriate boxes below:

- None -▾

- None -
Physiotherapy
Occupational Therapy
Psychiatry
Psychology
Arts Therapies
Positive Behaviour Support
Health Facilitation (including Acute Liaison)
Sight and Hearing
Speech and Language Therapy
IST - crisis support
Weight Management
Other…

Risk

Please provide details of any immediate risk

What are the risks for the person themselves?

Are there risks for other people?

Are there any risks for professionals from our team when we visit?

Are there any other challenges or issues that we need to know about before we work with this person?

Are you aware of any safeguarding issues?

Yes

Don't know

Other…

If yes, please provide details below

About You

Details about you, the referrer (Please give all details)

First Name

Last Name

Relationship to service user

Address

City/Town

ZIP/Postal Code

Phone

Mobile number

Your email

Professionals First Name

Last Name

Please provide details of current professionals involved. E.g. Community Mental Health, Wellbeing Hub, Social worker, Day Services

Title/Role

Address

City/Town

ZIP/Postal Code

Professionals telephone

Professionals email

Each referral may be allocated to a team or teams at the service’s weekly Referral Allocation Meeting based on needs and resources, not necessarily to the team/s suggested by you. Please note that some information in this form will be entered on the computer in accordance with the Data Protection Act. Some information may be shared with service colleagues on a need to know basis only.

Factors which MAY NOT indicate a learning disability

- Normal development until other factors impact (before 18). - Diagnosis of ADHD, dyslexia, dyspraxia or Asperger’s - Successfully attend mainstream education without support. - Gained qualifications (GCSE and/or A Levels) - Able to function socially without support - Able to complete complex purchases e. g. buying a house - Able to drive a car - Contact with mental health services - Recorded IQ above 70.

Factors which MAY indicate a indicate a learning disability

- Record of delayed development / difficulties with social functioning daily living before 18. - Requires significant assistance to provide for own survival (eating and drinking, keeping self-clean, warm and clothed) and/or with social / community adaptation (e.g. Social problem solving/reasoning). - NB need for assistance may be subtle. - Presence of all three criteria for LD i.e. Impairment of intellectual functioning/social adaptive functioning and age of onset. - Range of information presenting a picture of difficulties in a number of areas of function, not explainable by another ‘label’. - Contact with specialist Learning Disability consultant.

Please upload supporting document

One file only.
64 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

SPLD Learning Disability Referral Form

SPLD Learning Disability Referral Form

Referral to services for people who have a learning disability (SPLD) - Specialist Healthcare Team

Personal Details

Details of next of kin, or carer

GP Details

Reason for referral

Risk

About You

Learning Disability Screening Tool

Questions to consider

Does the person have difficulty with:

Factors which MAY NOT indicate a learning disability

Factors which MAY indicate a indicate a learning disability

Page last reviewed:

SPLD Learning Disability Referral Form

SPLD Learning Disability Referral Form

Referral to services for people who have a learning disability (SPLD) - Specialist Healthcare Team

Personal Details

Details of next of kin, or carer

GP Details

Consent

Reason for referral

Risk

About You

Learning Disability Screening Tool

Questions to consider

Does the person have difficulty with:

Factors which MAY NOT indicate a learning disability

Factors which MAY indicate a indicate a learning disability