Merton Uplift Professional Referral Form
Please give as much detail as possible.
(If not please state why not below)
Section A: To be completed for all referrals
To ensure clinical safety you may be contacted for further information. Please attach the following specific information.
EMIS summary (required for all GP referrals)
Please enter your up-to-date contact details
IF YES, please state language and dialect required:
Section B: Please provide as much information as you have available
Please give as much information as possible including current symptoms.
e.g. suicide, self-harm, risk of self-neglect, risk to others, protective factors.
Please note that we rely on information about risk to judge the urgency of a referral. If it is left blank we will assume there is no risk.
Please give details of type, quantity, frequency