Referral date Required
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Date of birth Required
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Address Required
Address verified as correct? Required
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Telephone number verified as correct? Required
Interpreter required? Required
Physical/learning disabilities? Required
Is the client aware that a referral has been made and consent has been given? Required
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Referrer address Required
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Is GP Newcastle CCG? Required
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Reason for referral

First presentation of psychotic symptoms? Required
Age 14-65? Required
Previous involvement with EIP services? Required
Has an organic cause been eliminated? Example: head injury, epilepsy, UTI Required
Previous history of prescribed antipsychotics? Required

Psychotic symptoms

Evidence of voice hearing, unusual ideas, paranoia, visions? Required
Have psychotic symptoms lasted longer than 7 days? Required
Have psychotic symptoms remitted within 7 days without treatment? Consider if could be BLIP Required
Evidence of distress? Required
Deterioration in functioning? Required
Family concerns? Required
Family history of psychosis / “Schizophrenia”? Required
Any involvement with services in the past or currently? Required
Current or past drug or alcohol use: Required
Is the person currently intoxicated? Required
Have symptoms subsided following withdrawal of substances? Required
Required

Risks

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You can contact us on 0191 287 6210 if you require any assistance filling in this form. 

Once referral is received, we may contact yourself or the client for further information, please ensure you have included accurate contact details so we can be in touch if required.

We aim to offer an assessment, if appropriate, within 14 days of receipt of referral however if you require urgent support, please contact the relevant Crisis Team on the details below:

Newcastle & Gateshead Crisis Team: 

Call NHS 111 and select the ‘Mental Health’ option. NHS 111 is free and available 24/7.
Text Service: 07919 228 548 (for those who are deaf or have communication difficulties)