Wheelchair Service Current Referral Form Wheelchair Service Complete Bedfordshire Community Health Services Referral Form Telephone No.: 0345 604 4064 Please complete initial referral section and corresponding numbered section Reason(s) for referral(s) Reason(s) for referral(s): for each service required Does the patient have a Bedfordshire GP? Yes No Patient Details Full Name (Inc. title) NHS Number Date of Birth Telephone No. Mobile No. Email Address Address Full Address Postcode Key Safe Location Key Safe No. Details of any pets Language & Ethnicity Main Spoken Language Ethnicity Interpreter required? Yes No Impairments to service access Physical/Communication impairments, especially if requires assistance with arranging appointments? Yes No If Yes, please specify Does patient require transport to attend appointments? Yes No If Yes, please specify Next of Kin/Carer Details Full Name Relation to patient Telephone No. Mobile No. Email Address Availability Agency Daily Care Package Involvement Does the patient have an appointed Power of attorney for health? If Yes, name and contact number of PoA for health. Yes No Name Contact Number GP Details GP Name GP Practice Name Telephone No. Address Email Address Referral Details Referral date Referrer Name Organisation Telephone No. Email Address A copy of your submission will be sent to the email address provided. Role Does the GP agree to notification by task that reports or letters have been written Yes No Signed Referral Consent Patient consented to referral? Yes No Patient informed of information sharing on SystmOne? Yes No Risk Assessment Living Circumstances Alone With family/friends Other If Other, please specify Housebound Yes No Able to open door Yes No If no, please provide details of contact person to arrange access Environmental Risk (Lone worker risks, inadequate lighting in area, secluded location, pets) Previous or current experience of mental health issues? Yes No If Yes, please specify Previous or current suicidal ideation/attempt/self-harm? Yes No If Yes, please specify Known to Mental Health Services? Yes No If Yes, please specify History of violence/aggression towards others? Yes No If Yes, please specify Current expressions of violence/ aggression /threatening behaviour? (either by patient or others living at the same address) Yes No If Yes, please specify Communication Difficulties Yes No If Yes, please specify MARS Chart Has MARS Chart been completed if being asked to administer medication Yes No If Yes, please specify Has DNAR been completed? Yes No If Yes, please specify Allergies Do you have any allergies? Yes No If Yes, please specify Hospital Discharge Referral Planned Discharge Date (if this changes Single Point of Access Must be Informed) Discharging Ward Attach Documents Unlimited number of files can be uploaded to this field.64 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Telephone No.