Name of referee *

Contact details of the referee :

Email *

Telephone *

Clients full name *

Date of Birth

Ethnic origin

Gender

  Male     Female

Current address

Contact email

Contact telephone number

Please provide details :

Are they in recovery? (for how long)

What substance are they in recovery from and for how long?

What treatment have they received from any a treatment organisation?

Please describe their mental health / wellbeing?

Do they have a mental health diagnosis condition?

Thinking about the support they need, please list what are your recovery goals you wish to work towards?

Are they receiving support from any other organisation?

Please describe the support you are getting and which organisation?

How did they hear about us?

Disclosure of information

  I understand the information that I have given today will be stored in a paper form as well as electronically. It has been explained to me that it will be stored securely in line with data protection policy. This information will only be stored for as long as necessary and will only be shared with your consent and in line with our safeguarding policy.