Personality Disorder Service Referral Form
Personality Disorder Service Referral Form (Jan 2016)
Please complete all sections including the patient supporting statement and questionnaire otherwise the form may be returned, resulting in a delay to the referral/ assessment process. We recommend that the referrer completes this form together with the person who is being referred.
|Date of referral: |Is this person currently receiving, been referred for, or waiting for any |
| |psychosocial intervention? ( Yes ( No |
| |Please give details: |
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|Referrer’s contact details: | |
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|Patient Name & |Does the patient have any children or dependents? |
|Title: |( Yes ( No |
| |If yes please specify, include ages: |
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| |Who looks after the children? |
|Address: | |
|Telephone number (please include mobile telephone number if applicable): |Name and details of emergency contact: |
|DOB: |Does the patient have a named person? |
| |( Yes ( No |
| |Name and contact details of named person: |
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| |Does the patient have an Advance Statement? |
| |( Yes ( No ( Not known |
| |If yes where can it be accessed: |
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| |On arrival at an assessment does the patient require any assistance (eg help |
| |with language, wheelchair access)? |
| |( Yes ( No |
| |If yes please specify: |
|CHI number: | |
|Unit number: | |
|Age |Gender | |
|Consultant psychiatrist (RMO) | |
|GP name | |
|Practice address | |
|Mental Health Act status: | |
|( Informal | |
|( Subject to MHA or other mental health legislation (please specify) | |
|Details of care plan: |
|Is the patient on the Care Program Approach? ( Yes ( No |
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|Name Frequency of Contact Context |
|( CPN |
|( GP |
|( Social Worker |
|( OT |
|( Support worker |
|( Psychiatrist |
|( Carer/ family/ friend |
|( Other |
|Name of senior psychiatrist who diagnosed personality disorder: |Please list any specific ICD-10 or DSM-IV personality disorders identified: |
| |( Paranoid (F60.0) |
| |( Schizoid (F60.1) |
| |( Schizotypal (DSM) |
| |( Antisocial/dissocial (F60.2) |
| |( Borderline (DSM, closest equivalent F60.3) |
| |( Histrionic (F60.4) |
| |( Obsessive-compulsive/anankastic (F60.5) |
| |( Narcissistic (DSM) |
| |( Anxious/avoidant (F60.6) |
| |( Dependent (F60.7) |
| |( Personality disorder, unspecified (F60.9) |
|Date of diagnosis of personality disorder: | |
|Working diagnoses (please include all current psychiatric diagnoses): | |
|Are the ICD-10 general criteria for personality disorder (below) currently met? |
|Yes( No( |
|A personality disorder is a severe disturbance in the characterological constitution and behavioural tendencies of the individual, usually involving |
|several areas of the personality, and nearly always associated with considerable personal and social disruption. Personality disorder tends to appear in |
|late childhood or adolescence and continues to be manifest into adulthood. |
|General diagnostic guidelines: |
|(a) markedly disharmonious attitudes and behaviour, involving usually several areas of functioning, e.g. affectivity, arousal, impulse control, ways of |
|perceiving and thinking, and style of relating to others; |
|(b) the abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness; |
|(c) the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations; |
|(d) the above manifestations always appear during childhood or adolescence and continue into adulthood; |
|(e) the disorder leads to considerable personal distress but this may only become apparent late in its course; |
|(f) the disorder is usually, but not invariably, associated with significant problems in occupational and social performance. |
|Briefly describe the current personality related difficulties |
|Cognitive-perceptual (eg perceptual disturbance, suspiciousness, dissociation): |
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|Behavioural (eg parasuicidal behaviour, overspending, eating disturbance): |
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|Affective (eg anxiousness, mood instability, anger, emptiness): |
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|Interpersonal (eg identity disturbance, unstable relationships, social avoidance): |
|Risk categories/Vulnerability factors: Comments: |Identify who specifically is at risk:|
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|( Violence |( Patient |
|( Harm to others |( Family member |
|( Suicide |( Carer |
|( Self Harm |( Public |
|( Risk to children |( Community staff |
|( Self neglect |( Nurses |
|( Substance misuse |( Doctors |
|( Exploitation by others |( Other hospital staff |
|( Medication effects/side effects |( Other (specify) |
|( Cessation of contact with service | |
|( Accidental injury | |
|( Physical injury | |
|( Sexual exploitation of or by others | |
|( Other | |
|Phase-based treatment: |
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|It is useful to think of the treatment of personality disorder using a phase-based model of recovery, with a primary treatment task in each phase. For the|
|most part, each phase should be addressed before moving on to the next, with behavioural stabilisation (phase 1) being necessary to safely tackle phases 2|
|and 3. |
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|Phase 1: Stabilisation (Making Stable): this phase deals with safety, containment and promotion of self-regulation and control. The focus is primarily on |
|the present. Interventions with a principal focus on Phase 1 include STEPPS and DBT. |
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|Phase 2: Exploration and Change (Making Sense): this phase can commence once stabilisation occurs, even temporarily. The aim is to identify and make |
|changes to the factors which underlie the unhelpful behaviours. This phase can involve dealing with the effects of trauma and dissociation; treating self |
|and interpersonal problems; and treating maladaptive traits. The focus is primarily on the past. Interventions with a principal focus on Phase 2 include |
|trauma-focused CBT, EMDR and DBT-PE. |
|The PDS currently only provides trauma-focused work within the context of DBT. Sector psychological therapy services should provide this work in other |
|cases. |
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|Phase 3: Integration and Synthesis (Making Connections): this phase is not so much about changing existing psychological and interpersonal structures and |
|processes as putting new ones in place. The aim is to promote a more integrated sense of self and a healthier interpersonal environment – this may include|
|new leisure activities, occupational/educational activities, new roles and relationships. The focus is primarily on the future. Interventions with a |
|principal focus on Phase 3 include Vocational Rehabilitation and the CAS Day Service. |
|Which phase of treatment do you think your patient needs at this time? Please explain reasons or give examples: |
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|What specific treatment for personality disorder has been offered until now? |
|Please explain why this patient’s care and treatment cannot be provided within general mental health services. |
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|Reason(s) for this referral to the PDS (please tick all that apply): |
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|( Severity ( |
|Complexity ( Lack |
|of treatment response ( Probable need for |
|early intervention ( Other |
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|Please provide details: |
|What outcome would you like from this referral: |
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|( Specialist assessment and treatment recommendations ( Assessment for Dialectical |
|Behaviour Therapy (DBT) |
|Please confirm that you have made your patient aware that if they have previously received DBT then they are unlikely to be offered DBT again: ( Yes |
|( No |
|( Assessment for Coping and Succeeding Day Service (CAS) ( Other (please provide details) |
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|Patients referred for assessment will not necessarily receive services direct from the PDS. All patients who complete the assessment process will receive |
|treatment recommendations but some (or all) components of the plan may be most appropriately implemented by services other than the PDS. |
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|Please confirm that you have explained this to your patient and have made clear that this referral is for ASSESSMENT ONLY in the first instance: ( Yes |
|( No |
|Past Psychiatric History Timeline Summary (please include details of all treatment episodes; admissions to psychiatric hospital; use of mental health |
|legislation; previous diagnoses; psychosocial and physical treatments and response to these treatments). Please continue on a separate sheet if necessary:|
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|Current or past significant use of alcohol, unprescribed and illegal drugs (please provide details, including details of any dependence or withdrawal |
|syndromes): |
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|Significant Past Medical History: |
|Current Medication (please provide details including indication, dose and compliance): |
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|Are there any known adverse drug reactions? ( Yes ( No If Yes please specify |
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|Any other relevant information: |
|IMPORTANT: Please see the attached forms which should be completed by the patient. We will be unable to process any referral until we receive the |
|clinician-completed referral form, the patient-completed Supporting Statement and the patient-completed Baseline Information Questionnaire |
|Patient-completed Supporting Statement attached ? ( Yes ( No |
|Patient-completed Baseline Information Questionnaire attached ? ( Yes ( No |
|Completed by: |
|Referrer Job Title: |
|Signature of referrer: |
|Signature of person being referred: |
|Please send completed referral forms to: |
|Donna Graham |
|PDS Secretary |
|Room 48, Greenfields House |
|New Craigs Hospital |
|Leachkin Road, Inverness IV3 8NP |
For Personality Disorder Service Use - Outcome of Request
|( Accept for assessment |Date assessment is to be carried out by |
|( Decline for assessment |Reason assessment declined |
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| |Recommended action if declined |
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|Signature | |
|Date | |
Baseline Information Questionnaire (Initial)
To be completed by the person being referred
|DATE OF COMPLETION : |NAME: |
| |DOB: |
SECTION 1
We would like to start by asking you about how you generally are in most situations:
| |In general: |Yes |No |
|1 |Do you have difficulty making and keeping friends? | | |
|2 |Would you normally describe yourself as a loner? | | |
|3 |In general, do you have difficulties trusting other people? | | |
|4 |Do you normally lose your temper easily? | | |
|5 |Are you normally an impulsive sort of person? | | |
|6 |Are you normally a worrier? | | |
|7 |In general are you a perfectionist? | | |
|8 |In general, do you depend on others a lot? | | |
|9 |Do you think there is anything about your personality, that is to say the way you generally are, that needs to | | |
| |be changed? | | |
SECTION 2
We would now like to ask your use of other services in the past 6 months – if this is hard to remember, perhaps you could guess!
| |In the past 6 months: |No |Once |2 or 3 |More than 3|
| | | | |times |times |
|1 |Did you make a routine (non-emergency) appointment to see your GP? | | | | |
|2 |Did you make an emergency appointment to see your GP? | | | | |
|3 |Did you attend an Accident and Emergency Department? | | | | |
|4 |Did you have an admission to hospital? | | | | |
|5 |Have you see a social worker, benefits or housing worker? | | | | |
|6 |Did you have contact with the Police? | | | | |
|7 |Were you arrested? | | | | |
|8 |Were you charged with an offence? | | | | |
|1 |Not at all unwell | |
|2 |Very mildly unwell | |
|3 |Mildly unwell | |
|4 |Moderately unwell | |
|5 |Markedly unwell | |
|6 |Severely unwell | |
|7 |Among the most extremely unwell | |
SECTION 3
How mentally unwell do you think you are at this time?
(Please put a tick in the box beside the item which you think describes you best at this time)
SECTION 4
On a scale from 1 to 100, how would you rate your current quality of life (where 100 represents best possible quality of life and 1 represents worst possible quality of life)?
I would rate my current quality of life as ...................... out of 100
|1 |Extremely unhopeful | |
|2 |Very unhopeful | |
|3 |Unhopeful | |
|4 |Neither hopeful nor unhopeful | |
|5 |Hopeful | |
|6 |Very hopeful | |
|7 |Extremely hopeful | |
SECTION 5
How hopeful are you that things will improve?
(Please put a tick in the box beside the item which you think describes you best at this time)
SECTION 6
Please consider the statements below and for each one, please circle the response which best fits your experience during the last six months?
|1 |I complete my tasks at work and home satisfactorily (please circle the most appropriate): |
| |Most of the time |Quite often |Sometimes |Not at all |
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|2 |I find my tasks at work and at home very stressful (please circle the most appropriate): |
| |Not at all |Sometimes |Quite often |Most of the time |
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|3 |I have no money problems (please circle the most appropriate): |
| |No problems at all |Slight worries only |Definite problems |Very severe problems |
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|4 |I have difficulties in getting and keeping close relationships (please circle the most appropriate): |
| |No problems at all |Occasional problems |Some problems |Severe difficulties |
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|5 |I have problems in my sex life (please circle the most appropriate): |
| |No problems at all |Occasional problems |Moderate problems |Severe difficulties |
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|6 |I get on well with my family and other relatives (please circle the most appropriate): |
| |Yes definitely |Yes usually |No, some problems |No, severe problems |
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|7 |I feel lonely and isolated from other people (please circle the most appropriate): |
| |Not at all |Not usually |Much of the time |Almost all the time |
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|8 |I enjoy my spare time (please circle the most appropriate): |
| |Very much |Sometimes |Not often |Not at all |
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|9 |I generally have difficulties getting on with people (please circle the most appropriate): |
| |Not at all |Not often |Sometimes |Very much |
|Supporting Statement for Referral to Personality Disorder Service |
|(to be completed by the person being referred) |
|Name: Date of birth: |
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|How does your personality disorder currently affect your life? |
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|What strengths or skills do you use to self-manage your health & wellbeing? |
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|What do you hope to gain from having an assessment by the Personality Disorder Service? |
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|I am happy to be referred to the Personality Disorder Service for assessment. |
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|Signed _______________________________________ |
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|Date _______________________________________ |
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Managing at home:
Getting out & about:
Work or education:
Relationships:
In any other way:
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