Referral – Part 1
COMMUNITY REHABILITATION TEAMS
PLEASE EMAIL ALL COMPLETED FORMS TO:  tspoa1@nhs.net
POST: Trafford Single Point of Access, Meadway Health Centre, Meadway, Sale, M33 4PS	
Consent & Hospital Information	
Client consent obtained? 	YES 	NO 	GP consent obtained?	YES 	NO 	
Is family/carer aware of referral?     	YES 	NO 	Ward:      	Hospital:      	
Patient Details	
Name	Full Name 	Address: Home Full Address (stacked)  	
Sex	Gender(full) 		
D.O. B	Date of Birth 		
NHS No	NHS Number 	
Marital Status 	     	Post Code	Home Address Postcode 	
Religion	Religion	Tel No	Patient Home Telephone 	
Ethnicity	Ethnic Origin 	Mobile No	Patient Mobile Telephone 	
Next of Kin/ Carer Details	
Name	     	Tel No	     	
Relationship	     	Mobile No	     	
Living arrangements and access to home details	
Does the patient live alone?	YES 	NO 	With family or a carer?	YES 	NO 	
Please specify if there are any special access arrangements (key code etc.) and provide details of how to retrieve this information when needed:      	
GP Details	
GP Name	Usual GP Full Name 	
GP Address	Organisation Full Address (single line) 	Post Code	Organisation Postcode 	
GP Tel No	Organisation Telephone Number 	
Referrer Details	
Name 	Free Text Prompt 	Tel No	Organisation Telephone Number 	
Job Title	     	Mobile No	     	
Base/Location	Organisation Name 	Email address	     	
Infection Control/ contraindication e.g. clostridium, MRSA, pacemaker etc.	
     	
Known Allergies	
Allergies 
	
Present diagnosis (include date of onset)	
     	
Reason for assessment:	
     	
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Referral – Part 2
Patient Name 	Full Name 	NHS No	NHS Number 	
Past medical history (or attach GP printout re patient’s medical history)  	
Problems 	
Key Agency details	
Key Agencies	     	
Frequency	     	
Care Package	YES 	NO 	Meals on wheels	YES 	NO 	Day Care	YES 	NO 	
Other
     	
Social Worker Details	
Name	     	Tel No	     	
Current medication (please provide printout)  	
     	
Additional information (please give dates of follow up/OPD appointments, details of any equipment issued, recent investigations i.e. blood tests, chest x-rays etc. details of security incidents affecting patients or staff)	
     	
What is likely to happen to your patient/client without intervention from Intermediate Care?	
     	
Is the patient at falls risk?         	YES 	NO 	
Are there any staff safety issues?	
     	
Communication	
First language (Please specify) Main Language 	
Interpreter required?	YES 	NO 	Is an Advocate required?	YES 	NO 	
Has this patient been given a diagnosis of a learning disability condition	YES 	NO 	
Other communication difficulties, please specify:       	
Hospital referrals only:	
ACTUAL date of discharge (Not MFFD or PDD)	Date:      	
PLEASE COMPLETE ALL SECTIONS OF THIS FORM AS ANY INCOMPLETE REFERRALS WILL BE REJECTED AND RETURNED TO THE REFERER	
Signature of referrer
	     	Date	     	
PLEASE E-MAIL ALL COMPLETED FORMS TO:  tspoa1@nhs.net
POST: Trafford Single Point of Access, Meadway Health Centre, Meadway, Sale M33 4PS	
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Community Rehabilitation Team & Community Neuro Rehabilitation
Triage - Team Priority Decision	
Patient Name	Full Name 	
Nhs no	NHS Number 	Date of Birth	Date of Birth 	
Person’s understanding of reason for referral:	
     	
Person’s perceived needs:	
     	
Falls Risk Assessment	
Score 1 for every category and total at the bottom of the two columns	YES	NO	
1	Is there a history of any fall/s in the previous year? 
How was this assessed? Ask the person.			
2	Is the patient/client on four or more medications per day? How was this assessed? Identify the number of prescribed or over the counter medications.			
3	Does the patient /client have a diagnosis of stroke or Parkinson’s?
How was this assessed? Ask the person.			
4	Does the patient/client report any problems with their balance? How was this assessed? Ask the person.			
5	Is the patient/client unable to rise from a chair of knee height? How was this assessed?  Ask the person to stand up from a chair of knee height without using their arms.			
Total: 
2+ = Falls Risk	     	
General Assessment	Additional Information	
Live alone?	     	
Mobile status: aids used?	     	
Transfers – toilets, chair, bed?	     	
Mobility on stairs?	     	
Package of care? 	     	
Able to make a hot drink/meal? 	     	
Manage personal care?	     	
	
Name	     	Signature	     	
Profession	     	Base/Location	     	

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Triage Outcome	
Patients Name	Full Name 	
NHS No	NHS Number 	Date of Birth	Date of Birth 	
COMMUNITY REHABILITATION TEAM – Identify the priority 1, 2 or 3	
PRIORITY 1
Within 2 weeks	PRIORITY 2
2 – 4 weeks	PRIORITY 3
Within 6 weeks	
Carer not coping	Orthopaedic condition which is safe and will progress (fractured NOF/ THR) and set up from hospital	Not acute deterioration- long standing (i.e. chronic conditions)
	
Cancer/Palliative	Reduced mobility and safe	Poor potential for recovery	
Orthopaedic i.e. TKR, frozen shoulder, fractured wrist	Needs rehabilitation to progress i.e. hoist to standing (safe)	Long standing other condition (CVA)	
Not managing transfers			
Unsafe			
Frequent falls			
Small window of opportunity			
ORT (OUTPATIENT REHABILITATION TEAM) – identify the priority as 1 or 2	
PRIORITY 1
Within 2 weeks	PRIORITY 3
Within 6 weeks	
Carer not coping	Orthopaedic condition which is safe and will progress (fractured NOF/ THR) and set up from hospital	
Orthopaedic which will deteriorate i.e. TKR/ frozen shoulder/ fractured wrist	Reduced mobility and safe	
Elective ortho surgery – knees, shoulders	Needs rehabilitation to progress i.e. hoist to standing (safe)	
Frequent falls	Long standing other condition	
Small window of opportunity		
Acute CVA (transferred from CNRT)		
CNRT (COMMUNITY NEURO REHABILITATION TEAM) Neuro diagnosis requiring rehab programme	
PRIORITY 1
Within 2 weeks	PRIORITY 2
Within 6 weeks	PRIORITY 3
Within 12 weeks	
New neurological diagnosis.
Neurological symptoms affecting functional ADL’s resulting in identified risk.
	Neurological symptoms are affecting physical/psychological wellbeing. (Also, to include onward referral from any RSD service)
	Agreed review period using objective markers to enable self-review and referral back into the service.	
STROKE TEAM	
PRIORITY 1
Within 10 working days	PRIORITY 2
Within 2 - 6 weeks	PRIORITY 3
6	weeks +	
Swallowing risk	Discharged from stroke unit	Previous CVA referred with problems relating to previous CVA	
Diagnosed with CVA – not admitted to hospital	Exercise programme prescribed whilst in hospital	Poor potential for improvement	
Falls	Requires rehab programme to progress abilities and is safe		
Moving and handling risk			
Carer not coping			
Difficulty with transfers			
Complaining of pain			
Date of triage		Priority 		
Date to be seen by (date sent to CPR)		
Name		Signature		
Profession		Base/Location		

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