“10-Step” Deliberate Self Harm Referral Form for Medical Staff alex.mitchell@leicspart.nhs.uk (v Oct 04)
1 Patient Name DOB A&E/Hospital No.
2 Referrers Name Consultant Referral Date and Time am/pm
(tick to indicate higher risk)….
Please complete in as much detail as possible Warning Boxes => √
3 What was the DSH Event (Presenting Complaint)? Checklist
Unusual or risky circumstances?
Believed method was dangerous/fatal?
Attempts at concealment or Final acts?
Intended to die?
4 What Medical Treatment was Required? Checklist
Admission required (if so where)?
ICU/ITU or Resuscitation required?
Antidote, sutures required?
Medical Complications or detoxification?
5 What are the Recent Stresses and Social Circumstances? Checklist
Relationship problems?
Housing problems?
Work or Financial problems?
Lack of social support?
6 What are the Background Factors (Clinical History)? Checklist
Past Psychiatric history?
Past Medical history?
Alcohol or Illicit Drug User?
Difficult Personal History?
Previous Self-Harm?
7 Are there any Psychiatric Symptoms or Signs? Checklist
Psychosis (odd thinking or beliefs)?
Dementia (memory, odd behaviour)?
Delirium (poor orientation or attention)?
Personality (self-destructive, impulsive)?
Depression (low interest, self-esteem)?
8 How would you Describe the Patient Now (Mental State)? Checklist
Appearance or Behaviour?
Speech or Thoughts?
Cognition or Insight?
Mood or Perceptions?
9 What is the Patients’ View of the Future (Risk Assessment)? Checklist
Refuses assessment?
Hopeless or Suicidal Thoughts?
Suicidal Plans or Conditional Threats?
Current Suicidal Intent?
10 State Outcome (referral or transfer to) If appropriate, please refer to
Department of Liaison Psychiatry
Brandon Unit, Leicester General Hospital
Self No FU I/P GP CMHPS Sector DSH Other (state)
D/C
In hours: (0116) 225 -6193 or Fax - 6173
Out of hours: page Duty ψ SHO