Learning Disabilities Forensic Outreach Liaison referral form Community Forensic Learning Disability Service ( LD Fols) referral form If you are making a referral, fill in the details below. Please complete as much of the information as possible. 123456 Does the person user have capacity to consent to this referral?* Yes No Does the person consent to this referral being made*If the user has capacity and does not consent we cannot proceed with the referral Yes No Is the referral being made in the person's best interest?*If you cannot answer yes then please do not proceed with the rest of the referral Yes Person detailsName* Prefix MrMrsMissMsDrProf.Rev.MxOther First Last NHS number EthnicityMake selectionWhite Britishwhite IrishAny other white backgroundWhite & Black CaribbeanWhite & black AfricanWhite & AsianAny other mixed / multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black /African/ Caribbean backgroundArabAny other ethnic groupNot stated/prefer not to sayPerson's stated sexual orientationMake selectionHeterosexual or straightGay or LesbianBisexualOther Sexual orientation not listedPerson asked and does not know or is not sureNot stated ( Person asked but declined to provide a response)Not known (not recorded)Gender Female Male non-binary/other Address Street Address Address Line 2 Town County Post Code Telephone Number/mobile numberAge Date of birth Day Month Year Reason for referral*Make selectionForensic risk assessmentOffence specific interventionCommunity transition support from a secure hospital or prisonForensic support and trainingOne-off consulation and adviceLonger team consultation and adviceType of riskSexual riskRisk of violent offendingAcquisitive offendingSubstance-related CJS involvementOtherExisting Legal Framework and Condition Court of Protection Safeguarding Sex Offender Register Guardianship Capacity Assessment DOLS MAPPA Consent to Treatment / Referrer CTO Details of relevant history, current concerns, risk areas & offending behaviourPrevious Treatment (s) and responsesCommunication dificultiesResponsible carer detailsName Prefix MrMrsMissMsDrProf.Rev. First Last RelationshipMake selectionSpousePartnerParentNext of kinGuardianFoster parentPolygamous partnerStep parentChildDependantNon dependantAddress Street Address Address Line 2 Town County Post Code Telephone Number /mobile number Case informationDetained under The Mental Health Act?* Yes No Further informationSubject to court imposed restrictions?* Yes No Further informationIs this person's placement funded by 117 aftercare? Yes No Not known Further information Is the person subject to DoLS/CoPDoL Yes No Not known Further informationIs the person subject to CPA* Yes No Date of last CPA* Day Month Year Has the person been subject to CTR?* Yes No Date of last CTR* Day Month Year Does the person receive annual health checks? Yes No Not known Date of last health check Day Month Year Confirmed diagnosis of learning disability* Yes No LD diagnostic reportpatients need a diagnosis of LD and ASD to access FOLS – please attach the diagnostic report to the form at the end. If you do not have access and cannot locate it, please give evidence below that demonstrates they have a LD or ASD (support received, daily living support needed, understanding, previous nursing, psychology or psychiatry reports etc Drop files here or Select files Accepted file types: jpg, jpeg, pdf, doc, docx, Max. file size: 10 MB, Max. files: 3. Learning disability informationConfirmed diagnosis of autism spectrum disorder* Yes No Diagnostic reportpatients need a diagnosis of LD and ASD to access FOLS – please attach the diagnostic report to the form at the end. If you do not have access and cannot locate it, please give evidence below that demonstrates they have a LD or ASD (support received, daily living support needed, understanding, previous nursing, psychology or psychiatry reports etc Drop files here or Select files Accepted file types: jpg, jpeg, pdf, doc, docx, Max. file size: 10 MB, Max. files: 3. Autism spectrum disorder informationType of accomodation/placement Prison Hospital (secure) Approved premises Own tenancy Lives with family Supported living Residential care Prison sentence typeMake selectionConcurrent and consecutive sentencesSuspended prison sentencesDeterminate prison sentences - fixed length of timeExtended Sentence for Public Protection (EPP)Extended Determinate Sentence (EDS)Indeterminate prison sentences (IPP) - no fixed length of timeLife sentencesWhole life termLength of prison sentence Prison Expected Date of Release (EDR)Please input monthsHospital date of admission Day Month Year Hospital projected date of discharge Day Month Year Are other teams involved ?Community Learnining Disablility team Mental Health Team Probation Service IST Social Services Yes No Further informationNamed care coordinator* Is the person on the dynamic risk register Yes No Not known Dynamic Risk Register RatingMake selectionAmberGreenRedBlue Responsible commissioning ICB and/or Local authority* Service user's current ICB Service user's GP Current Primary DiagnosisLearning disabilityAutistic spectrum disordersSchizophreniaSchizoaffective disorderPsychosisDelusional disorderBi PolarPost traumatic disorderDepressionObsessive compulsive disorderAnxietyAttention deficit disorderTourette’s syndrome/ tic disorderPersonality disorder: Antisocial, Avoidant, Borderline, Dependent, Histrionic, Obsessive compulsive, Paranoid, Schizoid, SchizotypalDementiaBrain injuryEpilepsySensory ImpairmentSecondary DiagnosisLearning disabilityAutistic spectrum disordersSchizophreniaSchizoaffective disorderPsychosisDelusional disorderBi PolarPost traumatic disorderDepressionObsessive compulsive disorderAnxietyAttention deficit disorderTourette’s syndrome/ tic disorderPersonality disorder: Antisocial, Avoidant, Borderline, Dependent, Histrionic, Obsessive compulsive, Paranoid, Schizoid, SchizotypalDementiaBrain injuryEpilepsySensory ImpairmentFurther notesRelevant documentationplease include any relevant additional documentation in support of the referral. e.g. OASys reports, offender supervisor reports, court reports, previous risk assessments, capacity assessments, parole dossiers, WAIS reports and mental health assessment reports, CPA/CTR minutes, MAPPA minutes, PNC, SHPO reports. Drop files here or Select files Accepted file types: jpg, jpeg, pdf, doc, docx, xls, xlsx, ppt, pptx, Max. file size: 20 MB. Referrer detailsReferrer name* Relationship to person Service/Provider Address Street Address Address Line 2 Town County Post Code Telephone number/Mobile numberEmailPlease use a secure email address if possible CAPTCHANameThis field is for validation purposes and should be left unchanged. Page last updated on: 19th January 2021