Over 21’s Referral

- Step 1 of 3

Are you making this referral for yourself or someone else? *

• Myself
• Someone else

Is the client aware of referral?

• Yes
• No

Name of person being referred *

First

Last

Date of birth of person being referred *

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Sex (at birth) of person being referred *

• Male
• Female
• Prefer not to say

We are asking this information so we can tailor support to your individual situation.

Do you have a fixed abode/address? *

• Yes
• No

Does the person being referred have a fixed abode/address? *

• Yes
• No

What type of address is this? *

• Home
• Temporary
• Correspondence only

What type of address is this? *

• Home
• Temporary
• Correspondence only

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Primary phone number of person being referred *

Please provide a contact phone number, such as a home or mobile number so that we can contact you.

Alternative phone number of person being referred

Is there another number we can reach you on. We will use this in case we cannot reach you on your primary phone number?

Email address

Preferred communication method *Select your preferred communication methodText message (SMS)EmailLetterAll of the above

How would you like us to keep in touch with you? We will use your preferred communication to send you updates such as appointment reminders.

Reason for referral *

• Alcohol only
• Alcohol and non-opiate
• Non-opiate only
• Opiate

We need to know this information so we know what type of support you will need from us. Examples of opiates include heroin and morphine. Examples of non-opiates include cocaine, ketamine and cannabis.

What are your goals for support and/or treatment? *

We ask this as everybody's goals are different and we can tailor support to what you want to achieve.

Preferred gender of your support worker *Select your preferred gender of your support workerMaleFemaleNo preference

It may not be possible to assign you a worker of your preferred gender, but if you do have a preference please let us know.

Do you have any communication needs? *

• No
• Yes

We ask for this information so that we know how best we can communicate with you and if any extra assistance will be required.

Please tell us what communication needs you have *

• Hearing
• Sight
• Speech
• Literacy
• Translation
• Other communication need

We will use this information to ensure our support considers how best we can communicate with you.

Do you have any physical health needs you would like us to consider? *

We are asking this question so that we can assess how best we can support any extra health needs you may have.

Do you have any mental health needs you would like us to consider? *

We are asking this question so that we can assess how best we can support any extra health needs you may have.

Please read the privacy script at the bottom of this page and let us know when you have done so by checking the correct option *

• I HAVE read the above statement
• I HAVE NOT read the above statement

We need to ask this so that we know you are making an informed choice to access our support. If you are referring someone else, this must have been read to them and understood.

Referrer name *

First

Last

Referrer organisation/source *

Referrer email address *

Referrer phone number *

The next stage of the form focuses on more personal questions. Are you happy to proceed? *

• Yes
• No

It is your choice whether you answer 'Yes' or 'No'. If you answer 'No', your assigned support worker will still need to ask these questions at your first appointment. If you begin to fill out the rest of the form and change your mind about answering the questions, you can click submit without completing everything and we will follow these questions up with you at a later date.

Next

What is your ethnicity?Select your ethnicity from the listWhite BritishAfricanAlbanianAny other groupArabAsian and ChineseBaltic Estonian/Latvian/LithuanianBangladeshi or British BangladeshiBlack and AsianBlack and ChineseBlack and WhiteBlack BritishBosnianBritish AsianBuddhistCaribbeanCaribbean AsianChineseChinese and WhiteCommonwealth (Russian) Indep StatesCornishCroatianCypriot (part not stated)East African AsianEnglishEthnic category not statedFilipinoGreekGreek CypriotGypsy/RomanyHinduIndian or British IndianItalianIranianIrish TravellerIsraeliJapaneseJewishKashmiriKosovanKurdishLatin AmericanMalaysianMauritian/Seychellois/Maldivian/St HelenaMid East (excl Israeli, Iranian & Arab)Mixed AsianMixed BlackMixed Irish and other WhiteMoroccanMuslimNigerianNorth AfricanNorthern IrishOther Asian or Asian unspecifiedOther Black or Black unspecifiedOther White European/European unsp/Mixed EuropeanOther Mixed or Mixed unspecifiedOther mixed WhiteOther republics former YugoslaviaOther White or White unspecifiedPakistani or British PakistaniPolishPunjabiScottishSerbianSikhSinhaleseSomaliSouth and Central AmericanSri LankanTamilTurkishTurkish CypriotUlster ScotsVietnameseWelshWhite and Black CaribbeanWhite and Black AfricanWhite and AsianWhite IrishUnknown

We are asking for this information so we can ensure our service is reaching people of different ethnicities equally.

What is your country of birth?Select your country of birth from the listUnited Kingdom of Great Britain and Northern IrelandAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArmeniaAustraliaAustriaAzerbaijanBahamasBangladeshBarbadosBelgiumBelizeBeninBhutanBoliviaBosnia - HerzegovniaBotswanaBrazilBritish Virgin islandBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape Verde islandsChadChileChinaCongoCosta RicaCroatiaCubaCyprusCzech republicDemocratic people's republic of KoreaDenmarkDjiboutiDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEstoniaEthiopiaFalkland islandsFijiFinlandFranceFrench GuianaFrench Polynesian islandGabonGeorgiaGermanyGhanaGreeceGrenadaGuadeloupe islandGuamGuatemalaGuernseyGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIslands of NetherlandsIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaltaMauritaniaMauritiusMexicoMonacoMongoliaMoroccoMozambiqueNamibiaNauruNepalNetherlandsNicaraguaNigerNigeriaNorwayOmanPakistanPanamaPapua New GuineaParaguayPeruPolandPortugalPuerto RicoQatarRepublic of IrelandRepublic of KoreaReunionRomaniaRussian federation - EuropeRwandaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSingaporeSlovakiaSloveniaSolomon islandsSomaliaSouth AfricaSouth GeorgiaSpainSri LankaSt. Vincent and the GrenadinesSudanSurinameSwazilandSwedenSwitzerlandTajikistanThailandTogoTongaTrinidad and TobagoTunisiaTurkmenistanTuvaluUgandaUkraineUnited States of AmericaUruguayUS Virgin islandUzbekistanVanuatuVenezuelaVietnamWallis and Futuna islandsZambiaZimbabwe

We are asking for this information in case we may need translation services to complement the support we offer.

Have you accessed services for your substance use before?

• Yes
• No

We are asking for this information so we can assess your treatment needs in a personalised way.

What is your sexual orientationSelect your sexual orientation from the listGay or LesbianBisexualHeterosexual or StraightNot surePrefer not to say

We are asking for this information so we can ensure our service is reaching people of any sexual orientation equally.

Are you pregnant?Select yes or noYesNo

We need this information as people who are currently pregnant will be prioritised for support.

What is your religion/belief?Select your religion/belief from the listBaha'iBuddhistChristianHinduJainJewishMuslimPaganSikhZoroastrianOtherNonePrefer not to say

We are asking for this information so we can ensure our service is reaching people of different religions or beliefs equally.

What is your current housing situation?Select your current housing situation from the listOwns homeRented home only – self-contained – private landlordRented home only – self-contained – social landlordRented home only – shares facilities – private landlordRented home only – shares facilities – social landlordOther – university or college accommodationOther – living with friends permanentlyOther – living with family permanentlyOther – supported accommodationOther – healthcare settingOther – accommodation tied to job (including armed forces)Other – approved premisesOther – authorised Gypsy and Traveller siteNo home of own – living with friends as a short-term guestNo home of own – living with family as a short-term guestNo home of own – sofa surfing (sleeps on different friends’ floor or sofa each night)No home of own – living on the streets/rough sleepingNo home of own – squattingNo home of own – night/winter shelterNo home of own – bed and breakfast/hotelNo home of own – hostelNo home of own – supported accommodationNo home of own – temporary housingNo home of own - unauthorised Gypsy and Traveller encampment

We are asking this information as we may be able to provide support around your housing situation.

Are you at risk of becoming homeless in the next eight weeks?Select yes or noYesNo

We may be able to provide extra support if you answer 'yes'.

Do you have any disabilities?

• Behaviour and emotional
• Hearing
• Manual dexterity
• Learning disability
• Mobility and gross motor
• Perception of physical danger
• Personal, self-care and continence
• Progressive conditions and physical health
• Sight
• Speech
• Other
• No disability
• Prefer not to say

Please select up to three of these options. We are asking for this information so we can adapt our support to your situation.

What is your employment status?Select your employment status from the listRegular employmentPupil/studentLong term sick or disabledHomemakerUnemployed and seeking workNot receiving benefitsUnpaid voluntary workRetired from paid workUnemployed and not seeking workPrefer not to sayOther

We are asking for this information so we can tailor appointment times around your situation. Our service can also offer support/referrals to appropriate services in this area. We will never tell your employer that you are accessing support from us without your express permission.

How long in years has it been since you were last in employment? *Select the number of years from the listI have never been employedPrefer not to say012345678910111213141516171819202122232425262728293031323435363738394041424344454647484950515253545657585960616263646566676869707172737475

We are asking for this information as the service can offer support/referral opportunities to appropriate services depending on your situation.

Are you a veteran of the British armed forces?Select yes or noYesNoPrefer not to say

We are asking for this information so we can assess your treatment needs in a personalised way.

Do you have parental responsibilities for children under the age of 18?Select yes or noYesNoPrefer not to say

We are asking for this information so we can tailor appointment times around your needs. Our service can also offer support/referral opportunities to appropriate services in this area.

Do these children live with you? *Select an option from the listAll children live with meSome of the children live with meNone of the children live with mePrefer not to say

We are asking for this information so that we can tailor support to your situation.

How many children under 18 in total live in the same house as you? This includes those that you don't have parental responsibility for. Select the number from the list0123456789101112131415161718192021222324252627282930

We are asking for this information so we can tailor appointment times around your needs. Our service can also offer support/referral opportunities to appropriate services in this area.

Are any children you have parental responsibility for, or the ones living with you, receiving any help? *

• No
• Early Help (Family Support)
• Child in need (Local Authority Service)
• Has a child protection plan (Local Authority Service)
• Other
• Prefer not to say

Please select up to three options. Our service can also offer support/referral opportunities to appropriate services in this area.

Are you currently injecting drugs?Select the correct option from the listNo, but I previously haveYesNever injectedPrefer not to say

We are asking for this information so we can assess your treatment needs in a personalised way and offer appropriate interventions as soon as possible.

Do you have any mental health needs?Select yes, no or prefer not to sayYesNoPrefer not to say

We are asking this information so that we can assess how best we can support your mental health needs.

Are you receiving any treatment for your mental health? *

• No
• Already engaged with the community mental health team/other mental health services
• Engaged with NHS Talking Therapies (formerly known as Improving Access to Psychological Therapies, IAPT)
• Receiving mental health treatment from GP
• An identified space in a health-based place of safety for mental health crises
• Receiving psychosocial or pharmacological intervention for treatment of mental health problem in drug or alcohol services
• Prefer not to say

PreviousNext

How often do you have a drink containing alcohol?

• Never
• Monthly or less
• 2-4 times per month
• 2-3 times per week
• 4 or more times a week

How many units of alcohol do you drink on a typical day when you are drinking?

• 1 or 2
• 3 or 4
• 4 or 5
• 5 or 6
• 7, 8 or 9
• 10 or more

If you are unsure about alcohol units, there is a link to our alcohol units advice at the bottom of this page.

How often do you have six or more units of alcohol on one occasion?

• Never
• Less than monthly
• Monthly
• Weekly
• Daily or almost daily

If you are unsure about alcohol units, there is a link to our alcohol units advice at the bottom of this page.

How often during the last year have you found that you were not able to stop drinking once you had started?

• Never
• Less than monthly
• Monthly
• Weekly
• Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of drinking?

• Never
• Less than monthly
• Monthly
• Weekly
• Daily or almost daily

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

• Never
• Less than monthly
• Monthly
• Weekly
• Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?

• Never
• Less than monthly
• Monthly
• Weekly
• Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

• Never
• Less than monthly
• Monthly
• Weekly
• Daily or almost daily

Have you or someone else been injured as a result of your drinking?

• No
• Yes, but not in the last year
• Yes, during the last year

Has a relative or friend or doctor or another health worker been concerned about your drinking or suggested you cut down?

• No
• Yes, but not in the last year
• Yes, during the last year

Previous

Submit

Please read the following privacy script

This project is part of a charity called Humankind.

Our top priorities are your safety and helping you achieve your goals with us. To do this, we need to keep some information like your basic contact details and more sensitive information like your health details. This is called a “legitimate interest” to use your information.

We keep your information safe and only share it with others if there is a good reason. Most of the time we ask your consent before we share, and we will complete our consent process with you during your first appointments with us. Occasionally, we may need to share your information without seeking your consent if we are worried that you or someone else could be in danger. This is called safeguarding and is a UK law that all health and social care organisations must follow. We will usually be able to tell you what we have shared and to whom. We will provide a factsheet with examples when we meet.

Visit our understanding alcohol units advice page for more information on alcohol units and how to work out your intake.