Swanswell S Integrated Substance Misuse Service - Referral Form

Swanswell’s alcohol and drug recovery service (young persons substance misuse and families) Referral form Delivering services as part of Worcestershire Recovery Partnership

Swanswell is a national charity that believes everyone deserves the chance to change and be happy. We provide community-based alcohol, drug and support services.

This form is to be completed when you, or someone you know (19 years and under), requires support from Swanswell’s Young Person’s Substance Misuse Service or Young Person’s Families Service.

Or, if you or someone you know, is 19 years and over and requires support from our families service please tick the Adult Families Service below:

Referrals from other organisations Swanswell will require a copy of the:  risk assessment (dated within the last 3 months)  care plan (dated within the last 3 months)  consent to share information document

Young Person’s Substance Young Person’s Families Adult Families Service Misuse Service  Service   Source of  Self  Organisation  Family/Carer  Doctor referral  Other, please specify: Date of referral Referral taken by Referrer contact Referrer name number

Referrer email Referrer address address

Details about the person seeking a service from Swanswell Name Date of birth Address Postcode Phone number Mobile number Email address Preferred contact method  Letter  Phone  Mobile  Email

Any special requirements for accessing Swanswell services?

First language

Interpreter required?  Yes  No

Swanswell’s alcohol and drug recovery service (young persons substance misuse and families) – referral form 1 GPs name and address

Other agencies involved (including criminal justice agencies)

Referral reason

What do you/they hope to achieve from accessing support with Swanswell?

Name of Frequency How Amount alcohol/drug taken/used e.g. wine 1 x 70cl bottle Daily (every Oral Alcohol/drug use in the evening) Smoke last three months Sniff/snort Inject

Physical/mental health issues or concerns Name Dose Frequency

Prescribed medications

Risks Are you/they pregnant?  Yes  No  N/A Are you/they responsible for children?  Yes  No  N/A Do you/they need any support?  Yes  No Risk to self  Yes  No Risk to others  Yes  No Risk from others  Yes  No Safeguarding concerns, is there any social care and health involvement?  Yes  No If ‘yes’ to any of the above, please specify:

Person consented to this referral?  Yes  No Person aware of referral being  Yes  No made? Where did you hear about Swanswell?

Please send completed referrals form by fax/email to: If you have any questions, please contact us:

Swanswell T 01905 721 020 Castle House F 0871 895 2310 14 Castle Street E [email protected] Worcester E [email protected] WR1 3AD

Swanswell’s alcohol and drug recovery service (young persons substance misuse and families) – referral form 2 Confidentiality and information sharing

 We, your treatment service, ask you for information so that you can receive proper care and treatment  We keep your information, together with details of your care, because it may be needed if we see you again  You have the right to apply for access to any records kept about your health  Any information provided to one clinical team within Public Health England (PHE) will be available to other teams within Public Health England in order to provide continuity of care  Your information will be used for research and monitoring purposes  Information may be used by clinicians within Public Health England as part of a clinical audit or service evaluation process. This will involve combining information from all clients attending the service, and it will not be possible to identify individual clients  Sometimes this treatment service may need to share certain information (for example on the outcome of your treatment) with other treatment services involved in your care, and as part of your treatment  The sharing of sensitive personal information is strictly controlled by law. Anyone who receives information from us is also under a legal duty to only use the information for the purposes you have agreed to and to keep the information strictly confidential  We share some information about you with the National Drug Treatment Monitoring Service (NDTMS). This is the database used to collect information on drug and alcohol treatment provision. It is managed nationally by Public Health England, the body responsible for collecting drug and alcohol data and for overseeing drug misuse treatment in England  If you are involved in the Criminal Justice System we may also share information with the Drug Interventions Programme The National Drug Treatment Monitoring Service (NDTMS) (Young Person’s Substance Misuse Service)

 The NDTMS system involves collecting information about the type of treatment you receive from a treatment agency Sometimes you may be seen by more than one agency. Consequently, to avoid duplication of reporting, NDTMS may share information about you between the agencies from whom you may have received treatment  Your full name and address are NOT passed on to the NDTMS although some details are sent to minimise the risk of you being counted twice; for example your initials, date of birth, gender, postcode (partial unless there is local consent), ethnicity and local authority of residence  Some information from NDTMS is cross referenced with data from other government departments and reports are sent back by Public Health England to them, so that they can monitor the effectiveness of the national drug and alcohol strategies. However, by the time Public Health England reports from the NDTMS to other government departments it is always in the form of total numbers of people and there is nothing in the information that could be used to identify you.  Public Health England does not pass any identifiable information held on the NDTMS to the police or criminal justice agencies  Your information is held on the NDTMS for at least 8 years  Data from NDTMS is not placed on any register of addicts – no central register exists  Your information is very useful for helping to plan and develop services that can best meet your needs. In order to produce information that measures this, NDTMS data is matched with other government departments’ data. All data matching is undertaken by Public Health England, and at no point is your personal information shared with other government bodies.  If you do not want information about you to be passed on to Public Health England, you have a right to say this  If you wish to know more about the NDTMS (including why information is needed for the NDTMS, how information is handled within NDTMS and/ or the type of information collected for NDTMS and the time it is retained) please ask your key worker

Before information is requested from or passed on to another agency or person, your worker will talk to you about what needs to be shared. You are being asked to sign the following agreement to exchange specific information with other professionals involved in your care.

DECLARATION I have had the benefits of sharing information discussed with me. I understand that sharing of information between agencies identified is intended to support me in making the changes I have agreed to. I give permission for my worker to receive information and share information about my care.

Client’s Signature...... Date …………………

I have explained the Public Health England Confidentiality Policy to the client, including conditions for breach. I have given the client advice and information.

Assessor’s Signature...... Date…………………

Swanswell’s alcohol and drug recovery service (young persons substance misuse and families) – referral form 3