SPOC Referral Form and Checklist

REFERRAL TYPE Required Required Self Prison DRR Court Conditional GP Assessment Assessment Referral Services Referral Referral Referral Caution Follow up □ □ □ □ □ □ □ □ □ □ □ □ □ □ If other please specify ______SERVICE USER INFORMATION Client Name DOB

Address Telephone

GP Name & Address GP Tel. No.

DIVERSITY MONITORING Ethnic Origin Chinese

Mixed -White an d Bl Asian Black or White ac Mixed – White White Mixe Mixe Asian or Asian or Asian Black Black Chinese - Ir k Asian Not Stated British Irish C African British ari bb ea n

□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Religion Previously treated Jewi Musli Atheist/ Any Not No religion Buddhist Hindu Sikh Yes □ No □ □ □ □ □ □ □ □ □ □ □ □ REFERRAL INFORMATION Main drug of choice

Other drugs used REFERRAL SOURCE INFORMATION

Referrer’s Name Telephone

Organisation Fax

Address E mail

PRIORTY/RISK MANAGEMENT Mental Health Yes □ No □ Housing/Homeless Yes □ No □

Child Protection Yes □ No □ Domestic Violence Yes □ No □

Pregnant Yes □ No □ Vulnerable Adult/Safeguarding Yes □ No □

IV User Yes □ No □ Sex Worker Yes □ No □

Children under age of 5 Yes □ No □ Ages: Suicide attempt/ self harm Yes □ No □

ANY OTHER INFORMATION (PLEASE INDICATE ANY KNOWN RISKS)

For RIRS use only Date referral received Date of assessment appointment Time of assessment appointment

Assessment Worker Venue