REFERRAL FOR TREATMENT AT BOSENCE FARM

Please complete this on behalf of your client, and ensure it is signed and dated by both of you at the end.

PERSONAL DETAILS

First Name: Surname:

DoB: Age: Male / Female

NI Number: NHS Number:

Any other / previous Name / Alias:

DSS benefits: Y N Details: Occupation:

Address: Contact Details:

Day: Evening: Post Code: Mobile: Nationality:

Marital Status: Disability: Yes No

Single □ Married □ Partner □ Visual Impairment □ Hearing Impairment □ Separated □ Co-habiting □ Physical Disability □ Learning Disability □ Divorced □ Widowed □ Dyslexia □ Other □

Details:

Next of Kin Details: Address: Name:

Relationship: Tel No:

Emergency contact if different: Consent to contact: Yes No

Referrer Details: Care Manager: Name of referrer:

Referring Agency: Contact details:

Funding agreed for admission to Bosence? Y N

Funding agency details:

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Other professionals: CPN: GP name: Probation Officer: Address: Social worker: Tel No: Other significant carer / professional:

REASON FOR REFERRAL

(please give full details)

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FAMILY: Which family members / close friends are supportive of your client seeking treatment:

Parental status:

Parent □ state number of children _____ No Children □

Social Services involvement? Y N

Social Worker details: ……………………………………………………………………………

Number of children living with your client: (please circle) 0 1 2 4 4+

Ages of children:

Is service user pregnant? Y N Details: Due date:

Please give any further details which might be relevant (e.g. safeguarding issues)

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DRUG USE (last 28 days) including amounts No. of First Others days Daily Substance Choice used IV Smoke Snort Oral per frequency week Alcohol

Amphetamine

Benzodiazepine

Cannabis

Cocaine

Crack

Heroin

Speedballing

Methadone

Other

DRUG USE HISTORY Age of first use: Ever injected? Y N Ever shared? Y N Age first injected?

Injecting sites:

Arms Y N Feet Y N Legs Y N Groin Y N Hands Y N Neck Y N Other: (please give details) ALCOHOL HISTORY

Drinking pattern:

Days drinking per week:

Units per day:

Age drinking began?

How long has drinking been a significant problem to service user?

Morning drinking?: Y N Age morning drinking began:

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PHYSICAL AND MENTAL HEALTH

Are there any concerns regarding your client’s physical health? Y N

(This could include: fits, heart problems, collapsed veins, wound care, sexual health, diet, DT’s tremors, hallucinations, pain at IV site) If Yes, please attach further details.

Current concerns:

Past history:

Allergies:

Are there any concerns regarding your client’s mental health? Y N

Is there a diagnosed learning difficulty? Y N

If Yes, request PCT Health Action Plan.

Date requested………………………………… by……………………………..

Has your client ever been seen by a psychiatrist / psychologist? Y N (please give details of who and when)

Current concerns:

Current Treatment:

Past History details:

History of self-harm or suicide? Y N

Current thoughts of self-harm or suicide? Y N

History of overdose? Y N

What? ………………………………………………………………………………………………..

When? ……………………………………………………………………………………………….

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Dual diagnosis? Y* N

Please give full further details if any of the above apply:

(* please note that for any referrals for the dual diagnosis service, additional documentation will be required in addition to the standard documentation – see details at the end of this form for what to include)

SEXUAL HEALTH

Sexually active / practicing safe sex (please delete as appropriate)

Sex worker status: Client declined □ No □ Selling on street □

Selling from Premises □

PRESCRIBED MEDICATION

Medication prescribed Y N Bought over the counter Y N Homeopathic or herbal remedies Y N Please give details below Drug Prescriber Route Dose

Is your client able to safely self-medicate their medicines? Y N

If not, please describe the support they need to be able to self-medicate.

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CRIMINAL ACTIVITY (pending, current, past – please give FULL details)

PLEASE NOTE WE MAY NOT TAKE ANYONE WITH A SEXUAL, RECENT VIOLENCE OR ARSON OFFENCE SUBJECT TO OUR RISK ASSESSMENT PROCEDURES.

Current:

Pending:

Past:

History of : (please give full details with dates if known)

Violent offence:

Arson:

Sexual offence:

Current bail / licence conditions? Y N

Details: ……………………………………………………………………………………………….

Court orders? Y N

Details: ………………………………………………………………………………………………..

CURRENT HOUSING

Living:

Alone □ With friends □ With partner □ With parent(s) □

Alone, with children □

Housing:

Homeless □ B&B □ Living in a hostel □ Rough Sleeper □ Squatting □

Tenant □ Supported Housing □ Temporary Accommodation □

Family / Friends □ Traveller □

Other □ ………………………………………………………………………………………….

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DISCHARGE PLAN

Does your client need a Detox prior to admission to Bosence? Y N

Please give details of any detox arrangements:

Has Funding been agreed for your client’s stay at Bosence? Y N

Is your client returning to the community after their stay at Bosence? Y N

If Yes, please indicate what support you have arranged in the community post discharge, including any contact details for the organisations:

Please give details of any other arrangements that are in place post discharge - e.g. housing, social support, education, training, employment, etc, including any contact details for the organisations: :

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TREATMENT OPTIONS CONSIDERED

Reason for wanting treatment at Bosence now:

Why Bosence?

What other treatment options have been explored?

PREVIOUS TREATMENT EXPERIENCE

Does your client have previous experience of detox / rehab? Y N If Yes, please give details of where and when:

What was the outcome?

What did your client find positive?

What did your client find negative?

Does your client have any 12-Step experience?

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PAST HISTORY

Is there anything significant in your client’s history that we should know about that might have an impact on their treatment?

Please continue on an extra sheet if required FUTURE PLANS

Please continue on an extra sheet if required

Referral form completed by: ……………………………………………………...……(Care Manager)

Date: ……………………………………….

Client signature: …………………………………………………………………………………………

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Date: ………………………………………. Before submitting this referral, please attach the current documents listed below:  Risk assessment and care plan  Preparation Plan-what preparation has been undertaken  Aftercare plan (what arrangements post Bosence are in place)  Contingency plan - for what will happen in the case of an unplanned discharge  Confirmation that funding is in place

For Dual Diagnosis referrals, please also include:  Recent report from consultant psychiatrist or CPN detailing current mental state and recent history as well as relapse signs and current medication prescribed.  If the client has had a recent admission, please also include ward discharge report

To enable a fast and effective response to your referral, please ensure all sections are completed. If there is information missing this may delay the application whilst we clarify details.

Please return all documents to our Administrative Team at:

Bosence Farm Community Ltd 69 Bosence Road Townshend Hayle Cornwall TR27 6AN

Or by email – [email protected]

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