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Home
Work With Us
Get Involved
Care and Housing Providers
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Annual Health Checks
LeDeR
Resources
General Resources
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Register For Staff Access
Training
Humber, North Yorkshire & York Dynamic Support Register & CETR Referral Document
Details of Referrer
Name
Role
Contact Details
Date of Completion
1. Are you also requesting a C(E)TR?
Select
Yes
No
2. Please advise the location of health services
Select
North Yorkshire
York
Hull
East Riding
North Lincolnshire
Northeast Lincolnshire
3. Where is the person ordinarily resident
Select
North Yorkshire
York
Hull
East Riding
North Lincolnshire
Northeast Lincolnshire
Other
4. Please select the primary risk
Select
1.At risk of admission to MH/LD hospital
2.At risk of losing placement
3.At risk of losing support
4.At risk of losing accommodation
5.At risk of admission to acute hospital for physical
6.Homeless
7.Forensic risk
8.Acute admission
9.Recently Discharged
10.At risk of admission to EDS
11. Other
5. Please advise the reason for the increase in risk
Select
1. Treatable MH need
2.Behavious of distress
3.Disordered Eating
4.Physical Health
5.Forensic
6.Substance Misuse
7.Serious self-harm/misadventure
8.Anti-social behaviours
9.Family Breakdown
10.Notice Served
11. Open Safeguarding
12.Other
6. Person's full name
7. NHS Number
8. LA Number (If applicable)
9. What is the persons Date of Birth?
10. Please provide the persons HOME Address?
11. Current housing type
Select
Family Home
Own Home
Residential
Nursing Home
Supported Accommodation
No fixed abode
Hostel
HMP
B&B
Other
12. If the person is currently in receipt of care and or support – please advise who is the provider and what care is currently in place, e.g. 1:1 24hrs,
13. Please advise any current funding sources such as PHB, Joint, S117, CHC etc..
14. What is the persons educational status (If applicable)
Select
52 week residential
38 week residential
Special school (term time)
Mainstream primary (term time)
Mainstream secondary (term time)
Mainstream college (term time)
Specialist college (term time)
University
Supported internship
Educated other than at school (EOTAS)
Not in education
15. Is there an EHCP in place? – provide details.
16. Details of any parents/carers (For CYP and young adults only)
17. Please provide GP Details
18. If the person has a Learning Disability, what is the date of the last Annual Health Check.
19. Are there any physical health issues – (please include any age-relevant screening)
20. Does the person have a diagnosed mental health condition?
21. Please provide details of any previous admissions to a mental health or LD specialist hospital
22. Is the person subject to any formal frameworks (such as LAC, DOL’s etc..)
23. Does the person have a Diagnosed Learning Disability?
24. Is the person Autistic with a formal diagnosis?
25. If the person is Autistic, please advise the year they received the diagnosis.
26. If the person is Autistic, have they had any post diagnostic follow-up. If yes what support have, they received?
27. Has there been any recent Care, (Education) and Treatment Review C(E)TR and/or Local Area Emergency Protocol Meeting (LAEP)? (Provide details)
28. Does the person have a care co-ordinator? (If not please advise why)
29. Does the person have a social worker? (If not please state why)
30. Please name any other lead/significant professionals involved
31. Has an advocate been offered/accepted and who is the advocate. Please state if the person has declined.
32. Does the person have any unpaid care such as family and is there a contingency plan in place if this was to breakdown?
33. Does the person have a risk management or safety plan in place and what date was it last reviewed.
34. Does the person require a referral to keyworker services? (for individuals 25 and under)
35. Does the person have an unmet housing need?
36. If the person is under 16, has parental consent been obtained?
Select
Yes
No
If no, please see top of page for template and submit this via the file upload below this question.
Upload Consent file (If required)
Choose File
No file chosen
Delete uploaded file
36a. If the person is 16 or over, has consent been obtained?
Select
Yes
No
If no, please see top of page for template and submit this via the file upload below this question.
Upload Consent file (If required)
Choose File
No file chosen
Delete uploaded file
37. If consent is not provided, then we CANNOT ACCEPT THE REFERRAL unless it has been deemed that the person lacks capacity, and this would be in their best interests. Formal documentation to support this would need to be provided.
38. Please provide details of the presenting problem, and highlighted risks – also include what has been implemented)
39. Please provide names and email addresses for all individuals you wish to be invited. Without this information we cannot arrange a CETR.
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