This is a referral form to a specialist domestic abuse perpetrator programme for men residing in Westminster, Kensington & Chelsea and Hammersmith & Fulham with drug and/or alcohol needs. If the client is in urgent need of medical attention please refer directly to Accident and Emergency services.

PLEASE SEND REFERRAL FORM TO -

North Westminster Drug & Alcohol Service

Tel: 020 7286 8001 Fax: 02072669397

E-mail:

Referrer’s Details
Referral Agency: / Referrer’s Name:
Referring Agency’s Address:
Postcode: .
Telephone: / Fax:
Email:
Client Contact Details
First Name: / Surname: / Also known as:
Address:
Postcode: .
Telephone Number: / Fax:
Email:
How would the client like to be contacted by the programme providers?
Please indicate if there is any preference on how the client would like to be contacted or stipulate if any methods should not be used.
Client Demographics
Gender:
Male Female Transgender / Date of Birth: Ethnicity: / Ethnicity:
Nationality: / Interpreter Needed:
Yes No If yes, in what language(s) ______
Does the client have any needs, which may hinder their ability to access the service:
Yes No If yes, please specify:
Details of partner/ ex-partner:
First Name: Surname: Also known as:

Address (if different to client’s address):
Postcode: .
Telephone Number: Fax:

Does the client have any children?
Yes No

Please provide their details below:
Name: Date of birth:
Name: Date of birth:
Name: Date of birth:
Name: Date of birth:
Name: Date of birth:

Please use this space to provide any further information with regards to the children.
For the Client
Do you acknowledge that your use of violence and/or abuse (emotional/ sexual/ psychological/ financial)
is problematic?
No / To some extent / Yes
Do you understand the programme that you are being referred to and have you been given information
about the programme?
Yes / No / Leaflet / Verbal information from
referrer
Informed that it’s a 26 week
programme

Do you have any mental health or cognitive problems that may affect your ability to participate in the
programme?
Yes No If yes, please specify:
Please list which substances (both prescribed and non-prescribed) you are currently using/have
previously used:
Substance / Route / Amount / Frequency / How long regularly used for? / Age of first use.
Please use this space to provide any further information:
For example, are you sharing equipment, or have you in the past? Dangerous injecting sites. If you are abstinent, when did you last use?
What is the medication prescribed for? Do you experience any side-effects?

Are you willing to engage fully in the programme?
Yes / No

Are you motivated to change your abusive behaviour?
Yes / No

Client Consent
I understand that the information I have given above will be shared with the substance misuse agency as part of the
referral process. To further assist the referral, where I have indicated my consent, I am happy for the substance misuse service to contact the agencies listed above.
Name: / Signature: / Date:
For the Referrer
Does the client demonstrate willingness and motivation to engage in the 26 week programme and change his behaviour?
No / To some extent / Yes
What treatment support is the client currently engaging with?
Key work sessions / Counselling / Groups
Day programme / ETE / Therapy
Other
Is there anything else you feel we should be aware of when conducting the assessment or delivering the programme?
E.g. risks to others or self, mental health issues. Please comment.
Referrer’s Name: / Signature: / Date: