www.rcpsych.ac.uk/plan

Joining form

	Subscription
	1 year £2900 +VAT
	2 years £5800 + VAT
	3 years £7830 (10% discount) + VAT
	4 years £9860 (15% discount) + VAT
	5 years £11600 (20% discount) + VAT

When your membership period ends, an invoice will be automatically raised until you decide to leave the network.                 At least one month’s notice to leave should be given. You will be asked to supply a PO number when your subscription is due for renewal.

Psychiatric Liaison team details

	Local project lead name:

	Local project lead person 2 (if applicable):

	Job title/designation:

	Unit name:

	Address:

	Tel:

	Fax:

	Email:

Invoice details

	Purchase order number (essential - please ask your finance department)

	For the attention of:

	Job title/designation:

	Address:

	Tel:

	Fax:

	Email:

Please provide some information about your service

	Which domains do you work within?
	Emergency mental health care to adults of all ages
	Routine mental health care to working age adults
	Routine mental health care to older adults
	Providing interventions
	Providing training to hospital colleagues

	Which hospital site(s) do you serve?

	Number of beds:

	Populations served:
	Working age adults (18-64)
	Older adults (65+)

	Working hours:

	Out of hours cover:

	Who are you funded by:

	Which hospital departments do you work with?

	What are the 3 most common problems you see?

	What are your service's strengths?

	What are the biggest challenges your service faces?

Thank you for completing this information.  Your form will now be submitted to the PLAN team, who will be in touch in due course.

If you have any questions, please get in touch: 0207 977 6646/6642 plan@cru.rcpsych.ac.uk

Royal College of Psychiatrists' Centre for Quality Improvement The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369) www.rcpsych.ac.uk © 2011 The Royal College of Psychiatrists