Tower Hamlets Community Health Services Referral Form	
Please e-mail this referral form back to: thgpcg.spa@nhs.net
Telephone No: 0300 033 5000
For referral and contact information for all services click: https://www.elft.nhs.uk/health-professionals/information-gps/i-am-gp-tower-hamlets 	

PLEASE USE (RP) SINGLE POINT OF ACCESS CHS REFERRAL TH CEG TEMPLATE IN ORDER TO COMPLETE THIS REFERRAL FORM 

Please select all services that require referral: 

Service(s) Required	
 1	Extended Primary Care Teams (EPCTs) – includes District Nurse, OT, Physio, Care Navigator, Mental Health Liaison Nurse, End of Life	 5	Community Diabetes Service	
 2	Rapid Response Team	 6	Nurse-led Community Heart Failure Team	
 3	Foot Health Service	 7	Adult Respiratory and Rehabilitation Care Service (ARCaRe)	
 4	Continence Service  	 8	Community Dietetics Service (excludes diabetes dietician needs – please refer to ‘Community Diabetes Service’)	
		 9	Community Neuro Team including Community Speech and Language Service (THCNT)	

[Referral required for service(s) listed below]
Medication for administration by District Nurses:  
[Referral Education about self management of diabetes]  

Patient Details	
Full Name (Inc. Title)		Telephone No.		
NHS Number:	 	Mobile No.	  	
Date of Birth		E-mail Address		
Housebound? (Mandatory information)	     

Full Address	

 	
Temporary Address	
Full Address:	

	
Postcode	
			
Next of Kin		Carer Details 	

Language & Ethnicity	
Main Spoken Language		Interpreter required?	
	
Communication needs	  	Ethnicity	

GP Referral Details	
Named GP		GP Practice Name		
Telephone No		Address	 

E-mail Address	 			
Referral Date		Referrer Name		
Organisation		Referrer GMC/NMC No:		
		Referrer role		

RISK ASSESSMENT – Mandatory section 
Are you aware of any environmental risk?	 	
Does patient have H/O Psychiatric Disorder? 	  	
Is the patient under any Mental Health Services?	 	
Does patient have H/O deliberate Self harm?	  	
History of Violent behaviour towards others? 		

Information of referral: 

[Consultation (3 latest consultations)]
[Medication list]