Make A Referral

Please ensure all sections of this form are completed





DETAILS OF PERSON BEING REFERRED

Name:

Date of Birth:

Age:

Gender:

Address:

Phone Number:

Postcode:

Email:

Current Accommodation:

If Other, please specify:

Consent to contact:
 Yes No

Consent to contact: Parent/Carer:
 Yes No

Looked After Child:
 Yes No

Disabilities:
 Yes No

If Yes, please give details:

Nationality:

Language:

Education and Empolyment:
 School College Training Employed Un-employed PRU SEN NEET Other

If Other, please specify:

SUBSTANCE USE

 Drugs Alcohol Other

Reason for Referral / Comments:

Please indicate main drug used:

Amount Used:

Frequency:

Injecting:
 Yes No

Details:

If abstinent, please state approximate time:

OTHER VULNERABILITES

 Health Mental Health Exploitation Domestic Violence Homelessness Gangs Other

Comments

OTHER AGENCIES INVOLVED

Name:

Agency:

Contact Details:

REFERRER DETAILS

Is this a self referral:
 Yes No

Date of Referral:

Does the service user know a referral has been made?:
 Yes No

Agency Name:

Contact Name:

Phone:

Fax:

Email:

CONTACT AND CONSENT

YP gives consent to this referral and to enter their information onto our Database?:

 Yes No

Would the Young Person like support for their parent/carer?:
If yes please make a referral to the Parent & Family Service
 Yes No

Young Person’s preferred method of contact:
 Letter Text Landline Mobile Via referrer

THERE IS A REQUIREMENT FOR THE REFERRER TO BE AVAILABLE AND MAINTAIN CONTACT WITH LIFELINE THROUGHOUT THE TREATMENT EPISODE AND MAY BE REQUIRED TO ATTEND AN UPDATE SESSION WITH THE CLIENT OR ASSIST IN MAKING CONTACT WITH THE CLIENT