Triage for the Dynamic Support Register

Section 1

Please indicate what you are requesting *Dynamic Support RegisterCommunity CTR/CETRInpatient CTR (Adults only)Local Area Emergency Protocol

Client Details *CYP (Children/Young people)Adult

Diagnosis *Learning DisabilityAutismMental Health Condition

Name

NHS Number

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

GP Name and Address

Advocate Details

Local Authority

Health Authority

School

Placement (52/38 week)

Parent/carer contact details (phone number and e-mail)

Consent *YesNo

Consent Document

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Section 2 - Support

Please Identify Current Support *HealthSocial CareEducation

Lead Worker

All allocated workers (please provide names and e-mail addresses)

Current Package of Care

Please attach details for Package of Care

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Does the CYP/Adult have a personal budget? *YesNo

Does the CYP/Adult have an EHCP? *YesNo

Please identify current reviewing/monitoring framework: *CPACINLACMDT

Section 3 - Risk

Please identify primary area of risk

Are there significant behaviours of concern? *YesNo

If yes, please identify

Has the CYP/Adult had contact with the Criminal Justice System/Prison service? *YesNo

Has the CYP/Adult previously been detained under the Mental Health Act? *YesNo

If yes, please identify section

Is the CYP/Adult in receipt of S117 aftercare? *YesNo

Is there a Crisis Contingency plan in place (Please attach)? *YesNo

Crisis Contingency plan attachment (If applicable)

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Has the CYP had a previous CETR/CTR/LAEP? *YesNo

If yes, please provide a copy of previous actions and recommendations

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Section 4 - CETR/CTR/LAEP Request

If requesting a CETR/CTR/LAEP and the individual is not known to the Dynamic Support Register please ensure sections 1,2 and 3 of this form are also completed to allow effective monitoring of any CETR/CTR/LAEP actions and recommendations .

Please identify (if there is a risk) how soon that risk might occur of admission to a mental health/learning disability hospital due to a mental health issue, behaviour of concern or placement breakdown within the community? *Within 24/48 hours (LAEP)Within 3 months (CETR/CTR)Inpatient CTR request (Adults only)

Please provide evidence of actions from the above

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Have you escalated concerns through your own organisation’s escalation process? *YesNo

If yes, please identify the name, contact details and outcome of escalation

Please identify who would require an invitation to a CETR/CTR/LAEP:

Please outline reason for CETR/CTR/LAEP Request: