Professional prevention referral

Has consent been obtained for referral?

Consent?*

Yes No

Details of referrer

Date of referral*

Name of referrer*

Job title*

Place of work*

Telephone number*

Email address*

Details of referred person

Full name*

Preferred name*

Date of birth*

Address*

Mobile number*

Landline number

Alternative telephone number*

Email address*

Occupation*

Nationality*

Race*

Relationship status*

Sexual orientation*

Religion*

Gender Identity*

Do they use a pro-noun?*

Yes No

Next of kin details

Next of kin name*

Next of kin relationship*

Next of kin telephone number*

Next of kin email address*

GP details – please provide complete information

GP name*

GP practice*

GP address *

GP telephone number*

GP email address*

Is the supported person currently been seen by any other service - i.e. crisis team, secondary mental health care, support worker, nurse practitioner, psychiatrist, third sector, family carer… (not definitive list)

Other service?*

Yes No

Name*

Job title*

Place of work*

Telephone number*

Email address*

Details of suicidal crisis (please be a detailed as possible)

Details*

Does this person have a history of suicide attempts?*

Has this person been bereaved by suicide?*

Does this person consider themselves to have a disability?*

Are there any risks to us or others we need to be aware of? Give details*

Are there any safeguarding issues we need to be aware of? Give details*

Does this person have any additional support needs? Language difficulties, hearing/visual impairment etc*

Are their current difficulties related to any of the following factors?

Relationship breakdown*

Yes No

Gambling*

Yes No

Debt*

Yes No

University*

Yes No

Work*

Yes No

Sexuality*

Yes No

Legal Problems*

Yes No

Family Problems*

Yes No

Bereavement*

Yes No

Drug/Alcohol Misuse*

Yes No

Professional prevention referral

Suicide prevention referral form

Has consent been obtained for referral?

Details of referrer

Details of referred person

Next of kin details

GP details – please provide complete information

Is the supported person currently been seen by any other service - i.e. crisis team, secondary mental health care, support worker, nurse practitioner, psychiatrist, third sector, family carer… (not definitive list)

Details of suicidal crisis (please be a detailed as possible)

Are their current difficulties related to any of the following factors?