Referral Form for The Sanctuary The Sanctuary is unable to accept those who have: 1) intoxication causing incoherence/ lack of cooperation and /or aggressive behaviour 2) self harmed at this time (rather than just thinking of self harming) 3) pose a risk of harm to others/ are behaving aggressively 3) made a current attempt to end their life or have expressed plans to imminently Date and time of referral contact call: Referral made to (site): Name of referrer: Role: Agency/organisation: Client Details First name: Surname: Date of Birth: DD / MM / YYYY Gender: Address Contact number: Home: Mobile: Please delete as Consent to contacted by letter YES / NO any further contact appropriate: Consent to be contacted by phone YES / NO Consent for voicemails to be left YES / NO Consent to be contacted by text YES / NO GP name & practice: The Sanctuary is accessed entirely voluntarily. Referrals will not be accepted without client consent. Has the client consent for this referral? Yes No NWAS ONLY Has an ambulance crew conducted a medical assessment with the client? (report to be submitted on arrival) Yes No GMP/BTP ONLY
Referral Form for The Sanctuary The Sanctuary is unable to accept those who have: 1) intoxication causing incoherence/ lack of cooperation and /or aggressive behaviour 2) self harmed at this time (rather than just thinking of self harming) 3) pose a risk of harm to others/ are behaving aggressively 3) made a current attempt to end their life or have expressed plans to imminently Date and time of referral contact call: Referral made to (site): Name of referrer: Role: Agency/organisation: Client Details First name: Surname: Date of Birth: DD / MM / YYYY Gender: Address Contact number: Home: Mobile: Please delete as appropriate: Consent to contacted by letter YES / NO any further contact Consent to be contacted by phone YES / NO Consent for voicemails to be left YES / NO Consent to be contacted by text YES / NO GP name & practice: The Sanctuary is accessed entirely voluntarily. Referrals will not be accepted without client consent. Has the client consent for this referral? Yes No NWAS ONLY Has an ambulance crew conducted a medical assessment with the client? (report to be submitted on arrival) Yes No GMP/BTP ONLY
Referral-Form-The-Sanctuary-SH080-v1.docx