Referral Form The Foothills Referral Form Referrer details please complete the following online form. Name of referrer: Your Position: Contact Details: Person being referred Name: Date of Birth: Current address: Mental Health Act Status: CPA Status: Section 117: YES/NO: YesNo Professionals involved: G.P: Consultant: Care Coordinator: Other: Current medication: Diagnosis & associated mental health needs (Emotional & behavioural presentation, insight & capacity): Reason for referral (Areas of identified support in the community & therapeutic needs): Identified risks (Please include historic and current risk assessment): Harm to self: Identified risks (Please include historic and current risk assessment): Harm to self: Harm to others: Self-neglect: Vulnerability: Additional personal needs (Cultural, spiritual & physical health needs including night time support required): Personal relationships & family structure: Additional information: Next of kin details/ Nearest Relative: Name: Address: Contact details: Date: Thank you for completing the form, please submit to us. One of our team members will be in touch shortly.