Referral Form

Please note as a Primary Care professional it may be quicker to make a referral to us via SystmOne or EMIS. If you are unsure how to do this, please contact us at linking.leeds@nhs.net

Patient Details

Full Name *

Address *

Postcode *

Gender *

Date of Birth *

Day
Month
Year

Contact Number (mobile if possible) *

Email (if available)

Preferred Contact Method * TelephoneEmailTextUnknown

Do you need an interpreter? *

If so, what language

GP Practice *

NHS Number (If available) *

Have they accessed Linking Leeds before? *
YesNoDon't Know

Please specify any accessibility requirements (physical/cognitive)

All of our staff can help you with your support needs. If the person you are referring has a specific reason for needing a worker of a certain gender, please state the reason/s below and we will do our best to provide this.

Details of Referrer

Name *

Which GP practice do you work for? *

What is your role in Primary Care? *

Contact Telephone Number *
Contact Email *

How long have you known the patient? *

Are we able to contact you further about this referral? * YesNo

Please indicate any perceived risk associated with the patient. *

No Risk / Low

Medium

High

Not Known

To Self No Risk / LowMediumHighNot Known

To staff No Risk / LowMediumHighNot Known

To Public No Risk / LowMediumHighNot Known

To Property No Risk / LowMediumHighNot Known

Substance Misuse No Risk / LowMediumHighNot Known

Offending No Risk / LowMediumHighNot Known

Domestic Abuse (survivor) No Risk / LowMediumHighNot Known

Domestic Abuse (person who abuses) No Risk / LowMediumHighNot Known

OtherNo Risk / LowMediumHighNot Known

Please give further details of any areas scoring medium or high *

Reason for Referral

Primary Reason (select the one that feels most relevant) *
Improve mental health and emotional wellbeingImprove physical health and wellbeingReduce social isolation or lonelinessFind out about local groups and activitiesConnect with housing servicesConnect with financial support servicesFind out about volunteering, employment, education and training

Secondary Reasons (Select as many that apply)
Improve mental health and emotional wellbeingImprove physical health and wellbeingReduce social isolation or lonelinessFind out about local groups and activitiesConnect with housing servicesConnect with financial support servicesFind out about volunteering, employment, education and training

Please provide a brief description for reason(s) for referral *

We no longer accept referrals from professionals outside of primary care. If you are working with someone who you think would benefit from our support, please encourage them to self-refer.

Patient Details

Details of Referrer

Risk

Reason for Referral

Details of person being referred

Your Details (as the person referring)

Your Details - (please complete the form as fully as possible)