IPS Self-referral form

The Individual Placement and Support (IPS) Employment Team provides support for people with mental health conditions who are already under teams within the adult community division within Lincolnshire Partnership NHS Foundation Trust and wish to receive support in finding or maintaining paid employment.

Please note that the IPS team support with employment and cannot provide an urgent/emergency service. If you feel you are at risk of harming yourself, or someone else please contact your GP or call 999 as a matter of urgency. You can also call NHS 111 for advice or the Mental Health Matters Helpline 24 hours a day for emotional support on 0800 001 4331.

Confidentiality Disclaimer

During your contact with Lincolnshire Partnership NHS Foundation Trust you will be asked to provide personal information to help us to deliver the best possible care to you. Everyone working for the NHS has a legal duty to maintain the highest level of confidentiality about all patient information.

The information you provide will be kept together and form a healthcare record. Healthcare records are mainly information held on the Trust patient administration system (computer) but sometimes there are additional paper records. Every reasonable precaution will be taken to safeguard the personal information you have entrusted to us.

Sometimes other agencies are also involved in your care and we may need to share information with them in order to deliver your care. Anyone who receives confidential information about you from us is also under a legal duty of confidence. We will not disclose your information outside these agencies without your knowledge unless the health and safety of yourself or others is at risk or if we are required by law under the Data Protection Act 2018.

You have a right to see and comment on any of the information we hold about you. If you do have any concerns or queries about this then please discuss this with the staff member you are in contact with. Further information about our legal basis for processing your information is detailed on our Trust website privacy policy and there is an additional leaflet How we use and share your information to help you. If you do not wish to have your records accessed for research purposes please visit https://digital.nhs.uk/services/national-data-opt-out-programme to set your choices.

I understand that this online referral will be considered, and I will be notified of the outcome and if an assessment and/or intervention is agreed then, I understand that I will be informed of the date(s) when this work will take place. Required

I confirm I have read and agree to the above Confidentiality Disclaimer. Required

I confirm I have read and agree to the above Confidentiality Disclaimer.

What is your name, date of birth, address, phone number and email address? Required

Please select if you are an LPFT staff member submitting this form on a service user’s behalf

What team are you under? Required

If you selected other, please specify

If you selected yes for the last question, are you, or will you be on a fast track?

Do you want support to secure paid employment?

If answered no, do you want support to retain current employment?

What is your background and reason for being referred? Required

Are there any known safety issues for meeting you or anything else we should know? Required

What is your preferred point of contact? Required

Should the first visit should be with your care coordinator? Required

Do you consent to a voicemail? Required

IPS Self-referral form

Confidentiality Disclaimer

Trust Headquarters

Useful Links

IPS Self-referral form

Confidentiality Disclaimer

Form

Trust Headquarters

Useful Links

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