About the service user

Reason for referral

Please tell us the reason and expectations for referral and any significant medical factors.

Please explain which of the following eligibility criteria the patient meets. The patient should have an associated cognitive behavioural or psychiatric disorder.

  • Parkinson’s Disease 
  • Huntington’s Disease
  • Multiple Sclerosis
  • Epilepsy & Non-Epileptic Seizures 
  • Head injury (chronic)
  • Brain lesions
  • Encephalitis
  • SLE
  • Tourette syndrome
  • Stroke
  • Early onset dementia (with complex needs)
  • COVID 19 associated cognitive impairment

Please include details of the following:

  • Contentious legal issues
  • Safeguarding concerns

It would also be helpful if you could include information such as:

  • Does the carer need support?
  • Has the GP discussed provisional diagnosis?
  • Significant events in last year e.g. death/retirement/ mood/life events.

Your patient

Next of kin (carer)


We are grateful for any additional information on potential risks or concerns regarding this referral such as:

  • violence and aggression
  • difficulty with engagement
  • significant self-neglect
  • safeguarding concerns
  • complex family dynamics
  • marked deterioration
  • falls
  • self-harm/suicidal ideation  

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