Interpersonal Trauma Response Service (ITRS) REFERRAL FORM

Referring Clinician (Name)

Referrers Email Address

Practice Name

Patient First Name

Patient Last Name

Patient Date of Birth

SAFE Telephone Number for the Patient

Is it safe to leave a message on the telephone

Patient Address 1

Patient Address 2

Patient Town

Patient Post Code

Is it safe to post information to the above address?

SAFE Email Address

Additional Contact Information

For example any disability or work pattern which may support our initial engagement.

Language/Interpreter required?

Are there ANY children under 18 in the household? (Include grandchildren)

Child Details - Name/DOB/Address (if different to patient)

Are there any vulnerable adults at risk in the family?

If so, how many?

Family already known to Social Services?

Details of Social Worker

Reason for Referral to ITRS

Consider high risk factors: SPECSSS – Separation; Pregnancy: Escalation; Community Isolation; Stalking; Sexual abuse; Strangulation.

Does the patient consent to FearFree sharing details of their support with their GP?