Application For Referral Form

Your Name: Your Email:

Information about the Applicant

*First Name: *Surname:

*D.O.B *Gender: Male Female 

*Home Address:

*Postcode:

*Tel: Mobile:

Email:

*Next of Kin:

*Contact Number: Relationship with Applicant: PartnerSiblingParentFriendOther

Background Information

Marital Status: SingleMarriedSeparatedDivorcedwith Partner

Ethnicity: White - BritishWhite - IrishWhite - Other BackgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - Other BackgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - Other backgroundBlack or Black British - CaribbeanBlack or Black British - AfricanBlack or Black British - Other backgroundChinese or other ethnic group - ChineseChinese or other ethnic group - Other ethnic groupNot Stated

Religion: No ReligionChristianBuddhistHinduJewishMuslimSikhAtheist/AgnosticAny other religion

Children - How many, of those how many are dependant on the client and do they live with the client?

Employment Status: EmployedUnemployedStudentRetiredOther

Main Occupation (if applicable)

If Unemployed, how long?

Does the client have any history of:  Arson Aggressive Behaviour Violent Behaviour Sexual Offences NO

Does the client have any outstanding legal issues? (on bail, probation, parole, suspended/deferred sentence, DTTO, awaiting charges/ trial/ sentencing or any ongoing court cases etc)  Yes No
If Yes, please give details:

Does the client have any criminal convictions?  Yes No
If Yes, please give details:

Medical

Surgery Name:

GP Name:

Address:

*Postcode:

Tel: Fax:

Email:

Does the GP know about the client's addiction? Yes No 

May we contact the client's GP? Yes No 

Please tell us about any current prescribed medication
Name, Dosage & Reason

Please tell us about any non-prescribed medication you are currently using:

Does the client have any of the following:

• health/ disability needs? Yes No 
  Details:
  
• dietary requirements? Yes No 
  Details:
  
• history of psychiatric illness, intervention or treatment? Yes No 
  Details:
  
• history of self-harm or suicide attempts? Yes No 
  Details:
  
• current illnesses / medical conditions? Yes No 
  Details:
  
• recurring illnesses / conditions? Yes No 
  Details:
  
• painful conditions? Yes No 
  Details:
  
• mobility problems (e.g. going up/down stairs)? Yes No 
  Details:
  

Alcohol Use

Please tell us about the client's alcohol use:
Type (Beer/Spirits), Amount & Frequency

Please tell us about any drugs the client has used in the past six months (e.g. heroin, crack, cocaine, methadone, cannabis, amphetamines, benzodiazepines etc):
Substance and Method of Use, Amount & Frequency

Referrer / Funding Details

Care Manager / Key Worker Name:

*Tel: Mobile:

Email:

Name of Referring Agency:

*Address:

*Postcode:

Funding

Funding by:

Funding Status: Approved Applied For 

Treatment Applied for: Detox Rehab Other 

Expected Length of Stay:

Name of Funding Agency:

Case Reference Number:

*Home Address:

*Postcode:

Contact Name:

Tel:

Fax: Email:

Please enter the characters in the box below.

By ticking this box I confirm that the details I have given are correct to the best of my knowledge and that by ticking this box I agree that any changes will be notified immediately.