Medway Active Recovery Service - Referral form Care-coordinator- Date of referral: Details of referral- Home Number: Preferred method of contact: Forename: Home phone Mobile Phone Text Letter Surname: No Preference Mobile number: (Previous Surname __________________________) Address: Date of Birth: Age: Can we leave a message on number/s provided? Postcode:______________ Gender: Please tick For No Abode Yes No Male Female Transgender Local authority of Residence: Nationality: Religion: Baha’i Buddhist Christian Hindu Medway Other Jain Jewish Muslim Pagan Sikh Zoroastrian (please state) _______________ Declines to disclose Religion Unknown None Sexuality (Please tick) Bisexual Heterosexual Homosexual Not disclosed Other Ethnic group: (Circle one) Currently registered with GP: Yes No A White British E & Black African K Bangladeshi R Chinese GP Name & Surgery details: B White Irish F White & Asian L Other Asian S Other C Other White G Other Mixed M Caribbean Z Not stated D White & Black H Indian N African Insert code here: Caribbean J Pakistani P Other black Name Of Referrer: How did you hear about the service? Referral Organisation: Contact details of referrer: Referral Organisation Further Details: (please tick) ATR Community Rehabilitation Company – ATR National Probation Service – DRR Community Rehabilitation Company – DRR National Probation Service – Voluntary (Self) Community Rehab. Company – Voluntary (Self) National Probation Service – Family Drug & Alcohol Email Address of referrer: Please tick to confirm consent has been given to make referral Reason for referral and other information please add any background you think may be useful ( additional sheets if necessary): Drug and/or Alcohol use: (Please state substances used in the last three months): Alcohol units per day- Drinking days in the last 28 days: Please add relevant details I.e. frequency, amounts used : Injecting status- Injected in last 28 days Currently sharing Ever shared Previously injected (not now) Never injected Declined to answer
Medway Active Recovery Service - Referral form Care-coordinator- Date of referral: Details of referral- Forename: Surname: (Previous Surname __________________________) Address: Postcode:______________ Please tick For No Abode Home Number: Mobile number: Can we leave a message on number/s provided? Yes No Preferred method of contact: Home phone Mobile Phone Text Letter No Preference Date of Birth: Age: Gender: Male Female Transgender Local authority of Residence: Medway Other (please state) _______________ Nationality: Religion: Baha’i Buddhist Christian Hindu Jain Jewish Muslim Pagan Sikh Zoroastrian Declines to disclose Religion Unknown None Sexuality (Please tick) Bisexual Heterosexual Homosexual Not disclosed Other Ethnic group: (Circle one) Currently registered with GP: Yes No GP Name & Surgery details: A White British E & Black African K Bangladeshi R Chinese B White Irish F White & Asian L Other Asian S Other C Other White G Other Mixed M Caribbean Z Not stated D White & Black Caribbean H Indian N African Insert code here: J Pakistani P Other black Name Of Referrer: How did you hear about the service? Referral Organisation: Contact details of referrer: Referral Organisation Further Details: (please tick) ATR – Community Rehabilitation Company ATR – National Probation Service DRR – Community Rehabilitation Company DRR – National Probation Service Voluntary (Self) – Community Rehab. Company Voluntary (Self) – National Probation Service Family Drug & Alcohol Email Address of referrer: Please tick to confirm consent has been given to make referral Reason for referral and other information please add any background you think may be useful ( additional sheets if necessary): Drug and/or Alcohol use: (Please state substances used in the last three months): Please add relevant details I.e. frequency, amounts used : Alcohol units per day- Drinking days in the last 28 days: Injecting status- Injected in last 28 days Currently sharing Ever shared Previously injected (not now) Never injected Declined to answer
Referral%20form%20for%20MARS%20-%20Draft%20v3.0%2029.07.16.docx