<p> 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</p><p>Address Telephone</p><p>GP Name & Address GP Tel. No.</p><p>DIVERSITY MONITORING Ethnic Origin Chinese </p><p>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</p><p>□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Religion Previously treated Jewi Musli Atheist/ Any Not No religion Buddhist Hindu Sikh Yes □ No □ □ □ □ □ □ □ □ □ □ □ □ REFERRAL INFORMATION Main drug of choice</p><p>Other drugs used REFERRAL SOURCE INFORMATION</p><p>Referrer’s Name Telephone</p><p>Organisation Fax</p><p>Address E mail</p><p>PRIORTY/RISK MANAGEMENT Mental Health Yes □ No □ Housing/Homeless Yes □ No □</p><p>Child Protection Yes □ No □ Domestic Violence Yes □ No □</p><p>Pregnant Yes □ No □ Vulnerable Adult/Safeguarding Yes □ No □</p><p>IV User Yes □ No □ Sex Worker Yes □ No □</p><p>Children under age of 5 Yes □ No □ Ages: Suicide attempt/ self harm Yes □ No □</p><p>ANY OTHER INFORMATION (PLEASE INDICATE ANY KNOWN RISKS)</p><p>For RIRS use only Date referral received Date of assessment appointment Time of assessment appointment</p><p>Assessment Worker Venue</p>