DVA Referral Form (D0904 0425)

Department of Veteran Affair's Referral Form **Patient Information** * **Patient Name:** John Smith * **Date of Birth:** 12/03/1978 * **Veteran Status:** Yes * **VA Facility:** Manchester VA Medical Center * **Patient Contact Number:** 07700 900123 * **Patient Address:** 123 High Street, Anytown, UK **Referring Provider Information** * **Provider Name:** Dr. Eleanor Vance * **Specialty:** Psychiatrist * **Contact Number:** 0161 123 4567 * **Email:** eleanor.vance@email.com * **Clinic:** The Priory Hospital, Manchester **Reason for Referral** * **Primary Diagnosis:** Major Depressive Disorder, Recurrent, Severe with Psychotic Features (F33.4) * **Secondary Diagnosis:** Post-Traumatic Stress Disorder (F43.1) * **Presenting Complaint:** Patient presents with worsening symptoms of depression, including anhedonia, suicidal ideation, and auditory hallucinations. He reports flashbacks related to his military service and difficulty sleeping. * **Duration of Symptoms:** Symptoms have progressively worsened over the past 3 months. * **Relevant History:** The patient is a veteran of the Iraq War. He has a history of substance abuse, now in remission. He has previously been admitted to a psychiatric unit for similar symptoms. **Treatment to Date** * **Medications:** Sertraline 200mg daily, Quetiapine 100mg at night. * **Therapy:** Cognitive Behavioral Therapy (CBT) with a private therapist. * **Response to Treatment:** Partial response to current medications and therapy. Suicidal ideation persists. **Requested Services** * **Specific Services Requested:** Inpatient psychiatric admission for stabilization and medication adjustment. Referral to a VA specialist for PTSD treatment. * **Urgency:** High. Patient's safety is a concern. **Supporting Documentation** * **Attached Documents:** Psychiatric evaluation, current medication list, and recent therapy notes. **Date:** 01 November 2024 **Signature:** Dr. Eleanor Vance