Community Therapy Team - professionals referral form

The below form is for healthcare professionals to refer patients to the Community Therapy Team.

The team accept patients who are:

registered with a Bournemouth, Poole or Christchurch GP
18 years of age or over
medically stable and safe to be in the community (we are not an urgent, intermediate care or rapid response service).

Please complete the form and a member of the team will be in touch.

Referrer name Required

Referrer role and team Required

Referrer contact number Required

Referrer email address Required

Has the patient consented to the referral?

Yes

Patient full name Required

Patient NHS number Required

Patient address Required

Address 1

Address 2

City

Country

County

Postal Code

Patient date of birth Required

Patient phone number Required

Patient GP's name Required

Patient GP practice Required

Please explain the reason for referral to the Community Therapy Team Required

Please include details of relevant past medical history Required

What is the patient's previous/normal level of function and mobility? Required

What is the patient's current level of function? Required

Please include details of abilities or difficulties with transfers (e.g. getting out of bed, standing up from a chair), standing, walking and aids used/required. Required

What are the patient's community rehabilitation goals? Required

Has the patient experienced any falls? Required

If yes, how many in the last week/month/year, and do you know the reason for the fall(s) If the patient has fallen 2 or more times in the past week, please consider referring to the intermediate care teams.

Have you referred to any other professionals about this issue / or are any other services involved? Required

Please advise of any other relevant information i.e. key codes, lone working, patient proxy etc Required

I agree to the privacy policy

You might also want to read...

Community Therapy Team - self-referral

Referral information for healthcare professionals

Useful links and resources