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Home
About
In this section
What we do
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Latest
In this section
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In this section
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View our vacancies
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Accessibility statement for Leicestershire Partnership NHS Trust
Mental health support
This is a test form - if you have found this page accidentally please do not try to complete the form as it will not be processed
LLR Dynamic Support Pathway Referral
Who is completing this referral
(Required)
I am completing this referral for myself or for a family member
I am a healthcare professional making a referral to the Dynamic Support Pathway
Name
(Required)
First name
Surname
Are you
(Required)
An adult (aged 18 or older)
Aged under 18
Date of birth
(Required)
Month
Day
Year
Ethnicity
White - British
White - Irish
White - any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Other Black background
Chinese
Any other
Not stated
Not known
NHS number
Gender
(Required)
Male
Female
Non-binary
Prefer to self-describe
Please describe
(Required)
Confirmed diagnosis
(Required)
Learning disability
Autism spectrum condition
Both of the above
GP details
Name of GP
(Required)
Address of registered GP practice
(Required)
Street Address
Address Line 2
City
County
Postcode
Your residence
Address of place of residence
(Required)
Street Address
Address Line 2
City
County
Postcode
Who do you live with?
(Required)
Education
Are you currently in education?
Yes
No
Current school
(Required)
School telephone number
(Required)
School email address
(Required)
Enter Email
Confirm Email
Communication
Preferred method of communication
Email
Telephone
Text
First language spoken
Reasonable adjustments required
Parent/carer details
Name of parent/carer
(Required)
Address of parent/carer
(Required)
Street Address
Address Line 2
City
County
Postcode
Parent/carer telephone number
(Required)
Parent/carer email address
(Required)
Enter Email
Confirm Email
Please tell us a little bit more: How are you feeling? What has happened? What is happening? Is there anything else you want to tell us about?
Information provided in this form will be shared with Barnados.
Date of multi-agency meeting (MaM)
(Required)
Month
Day
Year
If a MaM hasn’t been held, please arrange this prior to completing referral form - MaM must have been held within the last four weeks
Upload evidence of the MaM minutes
(Required)
Max. file size: 25 MB.
This referral is for
A child or young person
An adult
Has the person given consent to be added to the register?
(Required)
Yes
No
Does the person have capacity to consent under the MCA 2005?
(Required)
Yes
No
Is this documented on the consent form?
(Required)
Yes
No
If the person does not have capacity, has a Best Interest Decision been made and outcome recorded?
(Required)
Yes
No
Please review the updated referral criteria
before submitting a referral. Individuals must meet the criteria to be accepted onto the DSP. Please note that multiple changes have been made to the previous version, so it is essential that the criteria are checked carefully prior to submitting a referral.
Which of the referral criteria does the individual meet
(Required)
The person must meet at least one of the following criteria
Individuals who also have a mental health need who are at high risk of relapse or have unstable/untreated mental health needs that may lead to hospital admission.
Ongoing difficulty with the person’s behaviour causing risk of harm to themselves or others in the community - despite appropriate support and interventions already being in place.* *The DSP does not replace safeguarding pathways.
Which of the referral criteria does the individual meet
(Required)
As well as meeting one criteria from the previous question, the person must meet at least one of the following criteria
Individuals with multiple risk factors and behaviours that put themselves or others at risk of harm - placing their housing, family arrangements, care or support at risk of breakdown.
Individuals at high risk of being readmitted to a mental health hospital, including those on a Community Treatment Order (CTO).
Individuals currently in an acute mental health ward or a place of safety, including those with disordered eating or avoidant/restrictive intake disorders (ARFID).
Individuals in contact with, or involved in, the criminal justice system, including those with high risk of offending or reoffending.
Looked‑after children or young people placed out of area or in 52‑week residential placements (ensure receiving ICB is informed).
Referrer details
Name of referrer
(Required)
First name
Surname
Referrer role
(Required)
Referrer team
(Required)
Referrer telephone number
(Required)
Referrer email address
(Required)
Enter Email
Confirm Email
Details of the person being referred
Name
(Required)
First name
Surname
The person being referred is
(Required)
An adult (aged 18 or older)
Aged under 18
Date of birth
(Required)
Month
Day
Year
Ethnicity
White - British
White - Irish
White - any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Other Black background
Chinese
Any other
Not stated
Not known
NHS number
Gender
(Required)
Male
Female
Non-binary
Prefer to self-describe
Please describe
(Required)
Is the person at imminent risk of placement breakdown and/or admission?
(Required)
Yes
No
Please provide a reason why the person is at risk of placement breakdown and/or admission
(Required)
As you have selected no, please provide a reason for referral
(Required)
Confirmed diagnosis
(Required)
Learning disability
Autism spectrum condition
Both of the above
Do you have access to a proof of diagnosis report?
(Required)
Yes
No
Please upload the proof of diagnosis report
(Required)
Max. file size: 25 MB.
Why don't you have access to a proof of diagnosis report?
(Required)
Include information about any other diagnosis
Residence
Residence type
(Required)
Personal
Residential care
Supported living
Other (please state)
Please state the residence type
(Required)
Address of place of residence
(Required)
Street Address
Address Line 2
City
County
Postcode
GP details
Name of GP
(Required)
Address of registered GP practice
(Required)
Street Address
Address Line 2
City
County
Postcode
Education and care provider details (if applicable)
Is the person currently in education?
Yes
No
Current school
(Required)
School telephone number
(Required)
School email address
(Required)
Enter Email
Confirm Email
Looked After Child status (LAC)
(Required)
Current care provider (if applicable)
Care provider telephone number
Care provider email address
Enter Email
Confirm Email
Responsibility
Responsible Local Authority
(Required)
Leicester City Council
Leicestershire County Council
Rutland County Council
Child (under 18)
Not known
Who is responsible for funding current placement?
(Required)
LLR ICB
The Local Authority
Not known
Not applicable
How is the package of care funded?
(Required)
CHC
Social care
Joint
Section 117
Not known
Parent/carer details
Name of parent/carer
(Required)
Address of parent/carer
(Required)
Street Address
Address Line 2
City
County
Postcode
Parent/carer telephone number
(Required)
Parent/carer email address
(Required)
Enter Email
Confirm Email
Communication
Preferred method of communication
Email
Telephone
Text
First language spoken
Reasonable adjustments required
Brief history (last 12 months)
Please include information regarding previous inpatient admission (physical or psychiatric), previous placements, or forensic history. If the individual has previously been sectioned, please provide details of the location where the individual was detained and what section was applied (for example, S3, S37, S49)
Placement/admission
Date
Relevant details
Add
Remove
Overview of current situation
Please give an overview of the current situation and risks that have prompted this referral. Why are professionals/family cares concerned about the current situation? What care and support, education, occupation and treatment does the person currently receive.
Does the person have a current risk assessment with a contingency plan in place?
(Required)
Yes
No
Are there any safeguarding concerns?
Yes
No
Please provide details about any safeguarding concerns or referrals
(Required)
When was a referral made to safeguarding (if applicable)
Month
Day
Year
What additional support has already been put in place following identification of deterioration in health and wellbeing?
Meeting attendees (C(E)TR/MAM)
(Required)
Name
Role
Telephone number
Email address
Add
Remove
Please list the names and details of anyone who you believe needs to be invited to the meeting
Other information
Please include any other information that you think is important
Attach any other documents to support this application
Drop files here or
Select files
Max. file size: 25 MB.
This is a test form - if you have found this page accidentally please do not try to complete the form as it will not be processed
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