Over 21’s Referral

- Step 1 of 2

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

Middle

Last

Preferred name of person being referred

Let us know if your preferred name is different to the name above.

Date of birth of person being referred *

DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Sex (at birth) of person being referred *

• Male
• Female
• Prefer not to say

We are asking this information so we can tailor support to the person's 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 get in touch.

Alternative phone number of person being referred

Is there another number we can use? We will use this in case we cannot get through on the primary phone number.

Email address of the person being referred

Are we OK to write to you at your supplied address? *

• Yes
• No

Are we OK to write to them at their supplied address? *

• Yes
• No

How else would you like us to keep in touch with you? We will use your preferred communication to send you updates such as appointment reminders. *Select your preferred communication methodText message (SMS)EmailBothNeither

How else would you like us to keep in touch with them? We will use their preferred communication to send you updates such as appointment reminders. *Select your preferred communication methodText message (SMS)EmailBothNeither

Main reason for referral *Select a substance from the listAlcoholAmphetamines (excluding ecstasy)Anti-depressantsBarbituratesBenzodiazepinesCannabisCocaine (excluding crack)CrackEcstasyHallucinogensHeroinMajor tranquillisersMethadoneNovel Psychoactive SubstancesOther drugsOther opiatesPrescription drugsSolvents

We need to know this information so we know what type of support you will need from us.

Second reason for referral *Select a substance from the listNo second drugAlcoholAmphetamines (excluding ecstasy)Anti-depressantsBarbituratesBenzodiazepinesCannabisCocaine (excluding crack)CrackEcstasyHallucinogensHeroinMajor tranquillisersMethadoneNovel Psychoactive SubstancesOther drugsOther opiatesPrescription drugsSolvents

Let us know if you use another substance other than the one listed above. If you don't use a second substance, select "No second drug".

Third reason for referral *Select a substance from the listNo third drugAlcoholAmphetamines (excluding ecstasy)Anti-depressantsBarbituratesBenzodiazepinesCannabisCocaine (excluding crack)CrackEcstasyHallucinogensHeroinMajor tranquillisersMethadoneNovel Psychoactive SubstancesOther drugsOther opiatesPrescription drugsSolvents

Let us know if you use a third substance other than the two listed above. If you don't use a third substance, select "No third drug".

Please provide some details about the substance use frequency and amount used *

We ask this so we know what type of support we should be offering you.

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.

Preferred gender of support workerSelect their preferred gender of support workerMaleFemaleNo preference

It may not be possible to assign the person you are referring with their preferred gender, but if they 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.

Does the person have any communication needs?

• No
• Yes

We ask for this information so that we know how best we can communicate with the person being referred 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.

Please tell us what communication needs they 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 them.

Do you have any physical health or accessibility 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 *

Is there any other relevant information you would like to tell us about the person you are referring?

Next

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

Forward Leeds is a service made up of several key partners: Waythrough, BARCA-Leeds, St. Anne’s Community Services and Leeds and York Partnership NHS Foundation Trust..

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.