Icebreak Referral Form

Icebreak Referral Form
IMPORTANT UPDATE - ICEBREAK (Emerging Personality Disorder Service)

Due to the increased referrals and demand for Icebreak over recent years, we have needed to take the unfortunate decision to temporarily PAUSE accepting referrals for the service as from Monday 4th September 2023.
If you are in a mental health crisis and need urgent support:

Please contact FIRST RESPONSE via 111 (Option 2)
If you are aged over 18 yrs:

If you complete this referral form and consent to sharing, Primary Care Mental Health will respond and will provide advice of the appropriate local services available in relation to meeting your identified needs for supporting and maintaining your mental health and wellbeing OR you can either contact your GP and request a consultation to discuss your current mental health difficulties and possibly be referred to the ARRS worker in the GP surgery where they can refer to the appropriate services.
Do you consent to this referral and it's content being shared with The Mental Health Assessment and Intervention Service (MAIS)*

YES share this referral with MAIS?NO do NOT share this referral with MAIS?

Reason for Referral
What are your current main struggles or issues?*
Please note that it is essential that you fill this section in

Relationships and Family
Please provide some information about your current close relationships, including support networks (e.g. family, partner, friends, colleagues)

Suicidal Behaviours and Self-Harm

There may be times in a person's life when they become very low and may feel like taking drastic action:
Have you ever made an attempt to take your life?

YesNo
Please provide details including when this happened? (Month and year)
Have you ever harmed yourself without intending to kill yourself ?

YesNo
Please provide details including when this happened? (Month and year)

Smoking, Substance and Alcohol Use
Are you a smoker?

YesNo
How many do you smoke a day?
Would you like us to make a referral to the NHS Smoking Cessation team on your behalf to help you quit smoking?

YesNo
Please list any substance or alcohol use and the frequency you use them

Criminal Court and Family Court Activities
Please list any previous or current legal proceedings including child care and relevant dates:

Goals

Please identify up to 3 goals you would like to work towards. How would you like things to be different?
Goal 1
Goal 2
Goal 3

Employment Status and Education
Which of the following options best describes your current employment status?

Paid EmploymentLong term sick and in receipt of benefitsUnemployed and seeking workStudentUnpaid voluntary work and not looking for paid employmentHomemaker looking after family/home and not seeking workOther
What is your job?
Number of hours per week:
Where are you studying?
What course are you studying?
Have you ever served in the Armed Forces?

YesNo
Please provide details:

Information Sharing
Please list any people that you feel it would be helpful for Icebreak to share information with such as any family members or professionals you are working with and what sort of information you think it would be helpful to share.
Your Electronic Record

Please read the information in the link below and answer the questions relating to how you wish us to share your date
Sharing Out - Do you consent to the sharing of data recorded by Icebreak with other NHS organisations that may care for you?*

YES share data with other NHS organisationsNO do NOT share any data recorded by Icebreak; I fully accept the risks associated with this decision
Sharing In - Do you consent to Icebreak viewing data that is recorded at other NHS organisations and care services that may care for you?*

Yes, share data with Icebreak from other NHS organisationsNo, Consent declined; I fully understand and accept the risks associated with this decision
Your Summary Care Record
Do you consent to Icebreak accessing your Summary Care Record*

YesNo; I fully understand and accept the risks associated with this decision

By submitting this referral form I understand that I am consenting to engaging with Icebreak and understand the information provided to me within this referral. *

Clear
Please attach any additional information you feel might be helpful
Please add any additional information you think might be relevant:

Unfortunately we are unable to process your referral at this time.

If you are in need of mental health support you can either contact your GP and request a consultation to discuss your current mental health difficulties and possibly be referred to the ARRS worker in the GP surgery where they can refer to the appropriate services.

	Yes	No
Have any of your closest relationships been troubled by a lot of arguments or repeated breakups?
Have you deliberately hurt yourself physically (e.g. punched yourself, cut yourself, burned yourself)? How about a suicide attempt?
Have you had at least two other problems with impulsivity (e.g., eating binges and spending sprees, drinking too much and verbal outbursts)?
Have you been extremely moody?
Have you felt very angry a lot of the time? How about often acted in an angry or sarcastic manner?
Have you often been distrustful of other people?
Have you frequently felt unreal or as if things around you were unreal?
Have you chronically felt empty?
Have you often felt that you had no idea of who you are or that you have no identity?
Have you made desperate efforts to avoid feeling abandoned or being abandoned (e.g. repeatedly called someone to reassure yourself that he or she still cared, begged them not to leave you, clung to them physically)?

IMPORTANT UPDATE - ICEBREAK (Emerging Personality Disorder Service)