Getting the right help

Mental Health Crisis

Call 111 IMMEDIATELY!

Urgent help?

Please contact the Crisis Care Centre on:
0300 123 0907 Option 4

Routine referrals only

If you live in the Stoke-on-Trent or North Staffordshire, you can make a referral using the form below.

Learning disabilities - Online referral form

This referral form is to enable you or the person you support, to access the Community Learning Disability Team. If you need help filling in this form, please contact the CLDT on 03001231152.

Step 1 of 9

GP (Doctor) details

We only accept referrals for patients registered in the North Staffordshire and Stoke-on-Trent area.

Is the referred person registered with a GP in this area?(Required)

Yes

Is the person planning to move to this area and register with a GP?(Required)

Yes

As the referred person is not registered or planning on registering with a GP in our area, we are unable to proceed with your online referral. If you need further information with regard to this, please contact the CLDT on 03001231152 to discuss.

Please select the GP that you are planning on registering with.

GP Practice(Required)

If you do not know the GP's details, or you cannot find the GP practice, then please select "NONE OF THE ABOVE"

Please tell us approximately when you will be registered at the practice.(Required)

GP Name(Required)

If you are unsure of the referred person's GP, please call 03001231152 stating that you would like support in relation to GP details to enable you to process the online referral.

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GP_Is_In_Area_NR

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DEM_LORENZO_TEAM_NR(Required)

Referral to learning disability team code for Team: CLDT Stoke.

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GP_Decision_Value_1(Required)

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GP_Decision_Value_2(Required)

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GP_Decision_Value_3(Required)

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GP_Decision_Flag(Required)

Please tell us about yourself

When you see the phrase "Referrer" we mean you as the person who is making this referral to us.

Referrer's Name(Required)

First Last

Referrer's Address(Required)

Address line 1 Address line 2 (optional) City or Town County (optional) Postcode

Telephone (preferred)(Required)

e.g. 01234 567890

Other telephone

e.g. Mobile number

Email address(Required)

Enter Email Confirm Email

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Next of Kin and Carer details

Does the referred person have a Next of Kin?

Yes

Not known

Next of Kin name(Required)

First Last

Next of Kin Address(Required)

Address line 1 Address line 2 (optional) City or Town County (optional) Postcode

Telephone(Required)

e.g. 01234 567890

Main carer details(Required)

First Last

Type of carer(Required)

Paid carer

Family member

Friend

Other

Please tell us more(Required)

Main Carer Address(Required)

Address line 1 Address line 2 (optional) City or Town County (optional) Postcode

Telephone(Required)

e.g. 01234 567890

Mental Health Crisis

Call 111 IMMEDIATELY!

Urgent help?

Routine referrals only

Learning disabilities - Online referral form

This referral form is to enable you or the person you support, to access the Community Learning Disability Team. If you need help filling in this form, please contact the CLDT on 03001231152.

Pre-requisites

GP (Doctor) details

LD Register

Please tell us about yourself

Referred Person's details

Next of Kin and Carer details

Other professionals / agencies involved

Reason for referral

Contextual information

Mental Health Crisis

Call 111 IMMEDIATELY!

Urgent help?

Routine referrals only

Learning disabilities - Online referral formThis referral form is to enable you or the person you support, to access the Community Learning Disability Team. If you need help filling in this form, please contact the CLDT on 03001231152.

Pre-requisites

GP (Doctor) details

LD Register

Please tell us about yourself

Referred Person's details

Next of Kin and Carer details

Other professionals / agencies involved

Reason for referral

Contextual information

Learning disabilities - Online referral form

This referral form is to enable you or the person you support, to access the Community Learning Disability Team. If you need help filling in this form, please contact the CLDT on 03001231152.