Cogent Urgent Escalation Service

Client full name(Required)

First Last

Client date of birth(Required)

DD slash MM slash YYYY

Client email address(Required)

Client phone number(Required)

Reason for referral to Access Psych(Required)

Condition or diagnosis disclosed

Any indication of suicidality or self harm(Required)

Yes

No

Comments

If yes, indicate risk:

Current plan(Required)

Yes

No

Comments

Intention to carry out plan(Required)

Yes

No

Comments

Previous attempts(Required)

Yes

No

Comments

Risk status(Required)

Low

Medium

High

Name of Cogent consultant(Required)

Email address of Cogent consultant(Required)

Phone number of Cogent consultant(Required)

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