Vulnerable Access Clinic

Patient name*

Patient dob / chi*

Patient mobile number*

Patient next of kin*

Patient address*

Patient’s registered GP practice*

Referring organisation*

Name of referring key worker and contact number*

Has the patient been recently liberated from prison?*
YesNo

If yes, name of prison liberated from

Which category of vulnerability does the patient come under*
Severely mentally ill (including learning disabilities)Chaotic and dangerous drug useRisk taking behaviour (for example sex workers)Victims of traffickingRecently liberatedRefugees (legal or illegal)Homeless or in emergency accommodationVictims of abuse in crisis (for example domestic abuse)Patients presenting with provoked seizures identified in acute services.ENT referral pathwayOther

Brief description of any identified risks including to healthcare professionals (e.g. history of violence)

Brief description of barriers to patient achieving recovery. How can the clinic help?