Drug & Alcohol Single Point of Access
Authorised Access Only

Online DASPA Referral Form (TPN)

Welcome to the DASPA online referral form for professionals. Please be as detailed as possible and ensure all details are correct and accurate before submitting. We may be unable to process the referral if there is limited information and if this is the case, we will endeavour to contact you.

DASPA ONLINE REFERRAL

Please confirm that the person being referred has given consent. We will collect personal information which could be shared with referral organisations. We may have to contact you for further information if necessary to ensure the referral is forwarded to the correct team.For further information you can visit our Barod website.

DASPA Information

During this call we will collect personal information which could be shared with referral organisations. For further information you can visit our Barod website.
These will not shared when case is referred

Referrer Information

Please ensure your name and contact information is correct in order so we can contact you if necessary.

Client Information

If NFA provide letter only address here.
Excluding Child / Adult Protection Concerns including any NON Contact Information.

Living Arrangements

Risk Management

Think about risk of harm to self, risk of harm to others, any offences that have included violence, any risk of harm to lone workers? If none write N/A in box
Include any other significant criminal justice involvement, past or current?
**If none write N/A in box

Substances

Describe any treatment previously used for substance misuse issues.
Primary Substance
Secondary Substance
Other

Young People

Transitional Service

IVDU

BLOOD BORNE VIRUS' (BBV)

If yes, discuss BBV screening process.

Engagement Service

Please highlight any support needs to identify referral to Engagement Team

ABIS audit

(ABIS Audit)
(Audit) How often have you have 6 or more units (female) 8 (male) on a single occasion in the last year?

Health Profile

Please give an overview of current drug/alcohol use, how much, how often)
Include reasons why this is being prescribed and any other relevant information.

Other Agency Involvement

Support Needs

Include here any information in relation to restrictions on contact ie text only or where the client would like appointments (home / office / community)

DASPA Terms