CGL Tameside Tel: 0161 672 9420

Referral Form

Adult Young Person Family (DAFS) Young Carers (PIPS)

(Drug Alcohol Family Support) (People Impacted by Parental Substance Abuse)

Referral Date: / Referral taken by: / Triage by:
Please circle one / Family member / Service user / Preferred Location / Ashton/Hyde
First Name: / Surname: / Date of Birth:
Age: / Gender: M/F/Transgender/ Not Specified / Tel:
Address:
Postcode:
Ethnicity: / Nationality: / First Language:

Does your substance use impact on anyone else, e.g. Family, Children or Friends? YES NO Please tick if you DO NOT want an information pack to be sent Please provide details, e.g. name and address______

On contacting you for appointments what do you prefer: Please circle Phone/letter/text
GP Name: / GP surgery Name: / Tel:
GP Address
Postcode:
Do you consider yourself to have a disability / Yes/No

Referral Agents ONLY would you like to receive feedback Please circle YES or NO

Substance Use – please list alcohol, illicit and prescribed drugs used.

Substance / Prescribed YES/No / Frequency Daily/Weekly / Route of Use (Sniff, Smoke, Inject, Oral) / Amounts (units, grams, bags)
Risk and priority / Y / N / Don’t Know / Brief Details
Open to Social care?
Are they living with Children?
Children’s details?
Pregnant?
Vulnerable Adult or Child (please specify)
Urgent or current physical health issues?
Urgent or current mental health concerns?
Current risk of suicide or self-harm?
Risk of being harmed by others?
Presents a risk to staff/Known others/public?
Recently released from custody?
Would you be interested in receiving support stopping smoking?
Why do you want to access our service today?
Are you / is client subject to a court order whereby it is a requirement to engage? (if yes please specify: ATR / DRR / RAR/ licence condition) How long is the order/licence for?
Re-Engagement - Do we have your consent to contact you in the following if you fail to attend any offered appointments?
Ring you / Yes/No / Text you / Yes/No / Visit you / Yes/No
Do we have your consent to contact your child’s school? Yes/No
(If Young Person referral of school age, please note school details below)
School name: / Tel:
Address:
Postcode:
Are there any other agencies providing services to the client (that you are aware of? / Young Person
Are your parents aware of referral? YES/NO
Can appointment be arranged through school? YES/NO
Parent/Carer’s name:

“Please feel free to bring a family member or friend with you should you need additional support”

Initial Appointment Details: Mon/Tues/Weds/Thurs/Fri ____/____/____ @______hrs

With: EIP/Recovery/Aftercare (please state)

Referrer Details:

I have discussed my referral with the person concerned, who has consented to pass their information onto an appropriate substance misuse service.

Please circle one: Self/Referring Agent

Name: / Service:
Tel: / Date:
Address or Stamp

June 2017