Kinmos - Online Referals Form

Christian Hindu Muslim Buddhist Sikh Jewish Other Prefer not to say

Acocks Green Billesley Bournville Brandwood Edgbaston Hall Green Harborne Kings Norton Moseley and Kings Heath Northfield Selly Oak Sparkbrook Other

Violent ideation, extreme anger or hostility to others Violent threats or acts Suicidal ideation, expressed hopelessness, suicidal intent or attempts Threats or acts of self harm or mutilation Command hallucinations, persecutory delusions, morbid jealousy or delusions of passivity substance misuse or abuse Discontinuation of medicine Preparatory acts e.g making a will, buying weapons or planning a funeral Severe stress, loss events or threats of loss Concerns expressed by relatives, carers or significant others

Harm to adults - thoughts, fantasies or urges of harming others Harm to adults - emotional abuse to others Harm to adults - verbal abuse or threats of violence to others Harm to adults - physical assault or abuse to others Harm to adults - sexual assault or abuse to others Harm to older adults - thoughts, fantasies or urges of harming others Harm to older adults - emotional abuse to others Harm to older adults - verbal abuse or threats of violence to others Harm to older adults - physical assault or abuse to others Harm to older adults - sexual assault or abuse to others Harm to children - thoughts, fantasies or urges of harming others Harm to children - emotional abuse to others Harm to children - verbal abuse or threats of violence to others Harm to children - physical assault or abuse to others Harm to children - sexual assault or abuse to others Neglect of a child Neglect of an older adult Neglect of a dependent or disabled person Deliberate harm to self - suicidal thoughts, ideas or urges Deliberate harm to self - suicidal threats Deliberate harm to self - suicide attempts Deliberate harm to self - self harm or mutilation thoughts, ideas or urges Deliberate harm to self - self harm or mutilation threats Deliberate harm to self - incidents of self harm or mutilation Non- deliberate harm to self - neglect of diet, physical health or personal care Non- deliberate harm to self - neglect of personal safety or domestic risk Harm caused by others - has been the victim of exploitation Harm caused by others - has been the victim of physical abuse or assault Harm caused by others - has been the victim of sexual abuse or assault Other risk or behaviour - arson Other risk or behaviour - destruction or damage of property Other risk or behaviour - reckless behaviour, dangerous driving, careless smoking etc Other risk or behaviour - animal cruelty Noncompliance with medication Noncompliance with therapies Unplanned disengagement from services Admission to special hospital Admission to locked ward / ITU Admission to secure unit Informal admission Compulsory admission Forensic contact Drug abuse or misuse Alcohol abuse or misuse Command hallucination Paranoid delusions Morbid jealousy Arrests or convictions for violent offences Arrests or convictions for sexual offences Arrests or convictions for other offences Imprisonment Social vulnerability Social isolation Rootlessness