Referral for Treatment at Bosence Farm

REFERRAL FOR TREATMENT AT BOSENCE FARMPlease complete this on behalf of your client, and ensure it is signed and dated by both of you at the end.PERSONAL DETAILSFirst Name: Surname:DoB: Age: Male / FemaleNI 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 NoSingle □ 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 NoReferrer Details: Care Manager: Name of referrer:Referring Agency: Contact details:Funding agreed for admission to Bosence? Y NFunding agency details:Page 1 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMOther professionals: CPN: GP name: Probation Officer: Address: Social worker: Tel No: Other significant carer / professional:REASON FOR REFERRAL(please give full details)Page 2 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMFAMILY: 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)Page 3 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMDRUG USE (last 28 days) including amounts No. of First Others days Daily Substance Choice used IV Smoke Snort Oral per frequency week AlcoholAmphetamineBenzodiazepineCannabisCocaineCrackHeroinSpeedballingMethadoneOtherDRUG 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 HISTORYDrinking 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: Page 4 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMPHYSICAL AND MENTAL HEALTHAre 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 NCurrent thoughts of self-harm or suicide? Y NHistory of overdose? Y NWhat? ………………………………………………………………………………………………..When? ……………………………………………………………………………………………….Page 5 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMDual diagnosis? Y* NPlease 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 HEALTHSexually 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 DoseIs your client able to safely self-medicate their medicines? Y NIf not, please describe the support they need to be able to self-medicate.Page 6 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMCRIMINAL 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 NDetails: ……………………………………………………………………………………………….Court orders? Y N Details: ………………………………………………………………………………………………..CURRENT HOUSINGLiving: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 □ ………………………………………………………………………………………….Page 7 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMDISCHARGE PLANDoes your client need a Detox prior to admission to Bosence? Y NPlease give details of any detox arrangements:Has Funding been agreed for your client’s stay at Bosence? Y NIs your client returning to the community after their stay at Bosence? Y NIf 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: :Page 8 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMTREATMENT OPTIONS CONSIDEREDReason for wanting treatment at Bosence now:Why Bosence?What other treatment options have been explored?PREVIOUS TREATMENT EXPERIENCEDoes 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?Page 9 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMPAST HISTORYIs 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 PLANSPlease continue on an extra sheet if requiredReferral form completed by: ……………………………………………………...……(Care Manager)Date: ……………………………………….Client signature: …………………………………………………………………………………………Page 10 of 11 REFERRAL FOR TREATMENT AT BOSENCE FARMDate: ………………………………………. 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 placeFor 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 reportTo 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 6ANOr by email – [email protected]Page 11 of 11

Referral for Treatment at Bosence Farm

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