Referral Form

Alcohol Recovery Navigation Service

Please complete ALL fields. If you have any problems with this form please contact a staff member on 0161 873 7072

Details of Service User
/

Details of Referrer

Name / Name
Date of Birth / Age / Agency / Washway Road Medical Centre
Gender / Female Male
Address / Address / 67 Washway Road
SALE
Cheshire
Postcode / Postcode M33 7SS
Contact Number / Contact Number 0161 962 4354
Ethnicity / Has consent been given for
this referral? / Yes/ No
Permission to contact service user / Letter/ Phone / Does the service user consent
to referrer being involved in care plan / Yes/ No
Service User’s GP
/

Next of Kin

Name / Name
Practice / Washway Road
Medical Centre / Relationship
Address: / 67 Washway Road
SALE
Cheshire / Address
Postcode M33 7SS / Postcode
Contact Number 0161 962 4354 / Contact Number
Substance Details – Please detail all substances
Substance / Frequency / Quantity / How Taken / Days used in past week / Age First Used
Any daytime commitments? / Home visit requested? (Please state why)
Reason for referral, including what impact their use is having on their life (Family/ friends/ work etc) and what changes they would like to make

Is the service user working with any other agency, e.g. Probation? – Please list

Name / Contact Details

Does the service user have any diversity needs, e.g. interpreter? – Please list

Does the service user have any physical or mental health issues/disabilities?

Additional Comments

Once the form (above) and attached risk assessment (below) are completed please return to:

Address: Phoenix Futures Alcohol Recovery Navigation Service

58 Seymour Grove

Trafford

M16 0LN

Fax: 0161 873 7073

Risk Management Plan

- to accompany referral form

Risk to Self: Deliberate and Suicide
Yes / No / Unknown / Yes / No / Unknown
Depressed Mood (subjective) / Previous attempt (give details below)
Past History of Non-suicidal self harm / Suicidal Ideas
Plans made / Action Taken on plan
Dangerous irresponsible behaviour / Discovery avoided
Further Information, including any medication:
Accidental Overdose:
Yes / No / Unknown / Yes / No / Unknown
Poly Drug use / Regular IV use
History of past overdoses / Has witnessed overdose(s) by others
Injects alone
Further Information:
Risk to Others:
Yes / No / Unknown / Yes / No / Unknown
Past history of violence to others (inc sexual violence) / Prone to emotional arousal
Lack of regret / Conflict
Thoughts/Threats of violence / Paranoid thoughts/delusions
Identified target / Relevant Criminal record
Further Information:
Childcare:
Yes / No / Unknown / Yes / No / Unknown
Responsible for a child under 5 / Single parent
Currently pregnant / Intoxicated whilst solely responsible for child(ren)
Further Information:
Cannot cope with or needs help or prompting with:
Yes / No / Unknown / Yes / No / Unknown
Taking care of personal hygiene / Cooking for Self
Budgeting/Handling money/accommodation / Doing weekly shopping
Homeless/No Fixed abode
Further Information:
Road safety/machinery:
Yes / No / Unknown / Yes / No / Unknown
Drives/Works while intoxicated / Uncaring/indifferent to risk
Drives/Operates as part of job / Drinks/uses substances in work breaks
Drink – Driving Conviction
Further Information:
Level of risk to self:(High = 3 or more/Medium = 2/Low = 0-1) / Score:
Level of risk to others:(High = 3 or more/Medium = 2/low = 0-1) / Score:
Level of risk for personal safety:(High = 4 or more/Medium = 3/Low =0- 2) / Score:
Action to be taken on Medium risk presentation:
Action to be taken on high risk presentation by client, staff or other:
Additional Comments: