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, Care Navigator, Mental Health Liaison Nurse, End of Life	 6	Community Diabetes Service	
 2	Community Therapy Team – 
includes Occupational Therapy, Physio
	 7	Nurse-led Community Heart Failure Team	
 3	Urgent Community Response Service – 
includes Rapid Response, Falls Pick Up	 8	Adult Respiratory and Rehabilitation Care Service (ARCaRe)	
 4	Foot Health Service	 9	Community Dietetics Service (excludes diabetes dietician needs – please refer to ‘Community Diabetes Service’)	
 5	Continence Service  	 10	Community Neuro Team including Community Speech and Language Service (THCNT)	
		 11	Community Stroke Team

 

Medication for administration by District Nurses:  

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: