Leicester Alcohol & Drug Service Referral Form

Leicester Alcohol & Drug Service

Paget House

2 West Street

Leicester LE1 6XP

Telephone number: 0116 225 6400

Person Referred:
First name: ______Last name: ______
Address: ______
______Postcode: ______
Telephone number: / DOB: ___/___/___ Age:
Male Female
NHS Number:
Marital Status:
White - British Mixed White/Black Caribbean Asian – Indian Other – Chinese
White - Irish Mixed White/Black African Asian – Pakistani Other (specify)
White - Other Mixed White/Asian Asian – Bangladeshi Refused/Not asked
Black - Caribbean Mixed Other Asian - Other Not known
Black - African
Black - Other
Referrer Details: (please give your details below)
Name: Agency:
Address:
Postcode: Telephone No:
GP’s Name:
Address: / Medication: (Please indicate below any medication that this person is taking at present)
Contact with Mental Health Services: Yes No
Is the patient on CPA: Yes No /
Care Co-ordinator/Lead Professional’s name:
______
Risk Assessment
/
Yes
/
No
/
If YES Describe
Mental Health Issues / / /
Suicide Risk / Self Harm / / /
Violence/Harm to Others / / /
Offending Past/Present* / / /
Child Protection / / /
Physical Health / / /
Pregnancy / / /
Homelessness / / /
Domestic Violence / / /
Other Risks Identified / / /
Current Social Circumstances (relationships, living alone, support network)

*delete as appropriate

Current drinking pattern/consumption: (i.e. daily / weekly, amount, where, level of urgency)
Brief drinking history: (Including length of problem, previous contact with CAT/AAC/other)
Current drug use: (i.e. substance, frequency, dose, route of administration)
Brief Drug History: ((Including length of problem, previous treatment)

Other Agencies Involved:

GP Probation Social Services AA/NA

Hospital Prison Voluntary Agency Other:

Is the person able to travel for appointments: Yes No

Is the person aware of the referral: Yes No

If no, why not?: ______

Any Other Relevant Information: (eg interpreter required, access needs)

Referrers Signature: ______Date: ______

Client Consent to Telephone Contact (optional)

Should the patient wish the Community Alcohol Team to contact them by telephone to arrange their first appointment, please confirm telephone number to be used and obtain client signature. We are unable to accept verbal consent.

Telephone number:

Client Signature: Date:

For Office Use Only Triage Decision: Urgent Not appropriate
Non Urgent Refer on: ______

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