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Referral Assessment FormProfessional Support and Wellbeing servicePlease note that the content of this referral assessment form should be shared with the trainee before being sent. The referral agreement page must be signed by the trainee. Please complete every section (Light Green) in full. Failure to do so may hinder the process and subsequently the support that can be offered by the PSW. Once complete please send this form to psw.em@hee.nhs.ukPlease be aware that PSW does not accept referrals for trainees who are yet to sit an exam or have only had one attempt. We do accept trainee self-referrals for repeated exam fails. Other self-referrals will be considered on a case by case basis. Trainee InformationTrainee nameGMC/GDCnumberEmail addressMobile numberSpecialty & GradeSite of work Referrer Information (Self-referrals need to include supervisor info)Referrer namePosition (TPD/ES/CS/HOS)Email addressMobile numberDate completed Current PerformanceMost Recent ARCP OutcomeDate (MM/YY)Expected CCT Date (MM/YY)Any Mitigating Circumstances while being assessedIs the trainee currently on OOP? (tick) ?Is the trainee currently on Sick leave? (tick) ?Is the trainee currently on Parental leave? (tick) ?4) Referral ReasonPlease highlight the reason that best fits (more than one may apply)Anxiety/ StressAttitude & BehaviourHealthCommunicationConfidenceReturn to TrainingOrganisation/Time ManagementExamsPlease explain in further detail:5) Actions taken to datePlease list the actions that you have already taken to support traineeE.g. Meetings, regular appraisal, SMART targets set, involvement from TPD/HOS, Occupational Health (attach report if possible).Professional Support and Wellbeing Service AgreementAs you have been referred to the Professional Support and Wellbeing team (PSW) we would be grateful if you could read through the following information and sign to show you understand and agree with this:The aim of the PSW is to provide support for educational progression and hence to successful completion of your training programme. It is therefore expected that you will fully engage with the support that you are offered and that you will do so openly and respectfully. Support will be suspended if there are displays of anti-social behaviour. On completion of any PSW support you will also be required to complete an online feedback questionnaire.Please note that the details of your discussions with the PSW and/or any external supplier you are referred to for support will be confidential, except where there is a clear risk to yourself, others, including patients, or where there are significant concerns about health. All illegal activities will also be discussed with appropriate agencies. Whilst the detailed content of your discussion will remain confidential an update will be sent to your educational supervisor which will outline the reason for referral and the action plan that has been generated by the PSW.Providers of support are external to the NHS and hold qualifications in their area of expertise. Once you receive the contact details of a support provider you must either e-mail or phone them within two working days to arrange an initial session. If you do not contact them within this timeframe the PSW will suspend support and contact your educational supervisor. If you need to re-arrange or cancel a support session you must give 24 hours’ notice to the provider. If 24 hours’ notice is not given the PSW will be required to pay a cancellation fee and this will count as one of your allocated sessions. The PSW is required to submit a summary report to your ARCP panel which highlights the support you have received. This is a factual report which contains key dates and events. The content of your sessions will remain confidential however we will outline the areas that have been worked on. Furthermore, full occupational health reports and summaries of cognitive assessment reports will be shared with the ARCP panel. I confirm that I have read and accepted the above terms (tick) ?Please signify your agreement to the information above by signing here:Full trainee name:Date:Trainee Signature: