Drug & Alcohol Single Point of Access
Authorised Access Only

Online DASPA Referral Form (TPN)

Welcome to the DASPA online referral form for professionals. This form enables you to create a third party notification (TPN) that will instruct us to call a client to obtain further information about their needs. Please be as detailed as possible and ensure all details are correct and accurate before submitting.

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 include your email address if you would like feedback on this referral

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


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

Young People


ABIS audit

(ABIS Audit)
(ABIS Audit)
(ABIS Audit) How often have you had 6 or more units if female, or 8 or more if 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)