Cassel Hospital,
Specialist Personality Disorder Service,
1 Ham Common,
TW10 7JF

Tel: 020 8483 2900
Fax: 020 8483 2996

Date of referral
Which service do you think would be most appropriate for your patient? (Following screening and discussion we may recommend a different service) Required

Patient details

Date of birth

Referrer details


NHS staff details

(if applicable)

(e.g. housing, probation, social services, voluntary sector) 

(please describe current difficulties including diagnosis, risk factors etc. as well as the patient’s thoughts about this referral)

(Please provide a summary of the patient’s contact(s) with mental health services, beginning with the first presentation. Please include precipitating factors/risk behaviours and note the patient’s engagement with services if known)

(Please include physical health diagnoses, medications, etc.)

(Please provide a developmental history, including early experiences, significant losses or trauma, quality of family relationships, etc.)

(Please include education, employment, current living arrangements, forensic history, etc.)

(Please describe any safeguarding concerns and any previous safeguarding events)

Would the patient be able to attend a one-to-one assessment? Required