Referrer Information Agency Name Worker Name Date: Agency Address Postcode Telephone Fax Email Why are you Treatment: Advice: Client Type: referring the 1:1 Psychosocial Interventions Harm minimisation and Advice Criminal Justice client? Opiate substitute prescribing Pregnancy related Transitional ages (tick all that Group Programme Weight loss Healthier lifestyle apply) Alcohol Blood Pressure Alcohol / Opiate dependent Opiate detox Medication Recreational user Residential treatment Social factors Dual Diagnosis Relapse Prevention Other (please specify below) MAST Counselling Family & Friends support Hidden Harm Reintegration Unknown/To be confirmed as Traveller/ Gypsy community TBC as part of assessment part of assessment Orbit only Please provide details of substances used, including frequency and route if known. Reason for referral: Service User Information Service User Name Date of Birth Address Mobile no Gender Male Female Audit C Score: if known /applicable’ Is an Interpreter needed? Yes No If yes, please specify language GP Name & Address Is the client prescribed medication? Please provide details Is the client homeless? Yes No Has the client given Yes No Client signature: consent for the referral? Risk Please provide details of any risks known at the point of referral (including mental / physical health, vulnerability, etc)) Safeguarding children: Please provide details of service users’ children Is the client parent to child under 18 or has contact with children under 18? Yes No Name DOB Gender Address Contact Arrangements CP / CIN / LAC / TAF M/F / etc?
Referrer Information Agency Name Worker Name Date: Agency Address Postcode Telephone Fax Email Why are you referring the client? (tick all that apply) Treatment: 1:1 Psychosocial Interventions Opiate substitute prescribing Group Programme Alcohol Opiate detox Residential treatment Relapse Prevention Counselling Reintegration TBC as part of assessment Advice: Harm minimisation and Advice Pregnancy related Weight loss Blood Pressure Medication Social factors Other (please specify below) Family & Friends support Unknown/To be confirmed as part of assessment Client Type: Criminal Justice Transitional ages Healthier lifestyle Alcohol / Opiate dependent Recreational user Dual Diagnosis MAST Hidden Harm Traveller/ Gypsy community Orbit only Please provide details of substances used, including frequency and route if known. Reason for referral: Service User Information Service User Name Date of Birth Address Mobile no Gender Male Female Audit C Score: if known /applicable’ Is an Interpreter needed? Yes No If yes, please specify language GP Name & Address Is the client prescribed medication? Please provide details Is the client homeless? Yes No Has the client given consent for the referral? Yes No Client signature: Risk Please provide details of any risks known at the point of referral (including mental / physical health, vulnerability, etc)) Safeguarding children: Please provide details of service users’ children Is the client parent to child under 18 or has contact with children under 18? Yes No Name DOB Gender M/F Address Contact Arrangements CP / CIN / LAC / TAF / etc?
Referral-Form-v0.2.docx