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

Agreement

Call Disclaimer AgreedDuring this call we will collect personal information which could be shared with referral organisations. For further information you can visit our Barod website.

Would you like your DASPA assessment and support through the medium of Welsh?

Confidential DASPA Notes

These will not shared when case is referred

Call Handler name

Referrer Information

Referral Date

Referral Type

Self Referral Third Party Organisation Family / Concerned Other

Third Party Name / Organisation

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

Telephone

Address

Postcode

Additional Information

Client Information

First Name

Last Name

Nickname

Gender

DOB

Age

under 18

Area

Are parent(s) / guardian(s) aware of referral

Yes No

NHS Number

Address

If NFA provide letter only address here.

Postcode

Can letters be sent to this address if we are unable to contact you by telephone/mobile?

Residency

Permanent Temporary NFA

Telephone

Mobile

Preferred Contact

Telephone Mobile Post Email

Additional Contact Info

Excluding Child / Adult Protection Concerns including any NON Contact Information.

Employment Status

Armed Services Veteran

Yes No

Client willing to be contacted for SU questionnaire

Yes No

Living Arrangements

Who do you live with

Dependant Children

Additional Information

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

Criminal Involvement

Yes No

Additional Information

Include any other significant criminal justice involvement, past or current?

Child protection arrangements

**If none write N/A in box

Substances

Substance misuse issues

Describe any treatment previously used for substance misuse issues.

Primary Substance

Substance

Route

How Often

Amount

Age first used

Time Using

Prescribed

Yes No

Secondary Substance

Substance

Route

How Often

Amount

Time Using

Age first used

Prescribed

Yes No

Other

Substance

Route

How Often

Amount

Time Using

Age first used

Prescribed

Yes No

Young People

under 18

Primary Substance

Referrer

IVDU

IVDU: Do you ever inject

Currently Injecting Previously Injected Never Injected Unknown

IVDU: Have you ever shared?

Yes No Unknown

ABIS audit

How often do you have a drink containing alcohol

(ABIS Audit)

Typical units in a day when you are drinking

(ABIS Audit)

Unit Measurements

(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?

ABIS Total

Health Profile

Registered GP

Are you pregnant

Yes No N/A

Substance Use Overview

Please give an overview of current drug/alcohol use, how much, how often)

Prescribed Medication

Include reasons why this is being prescribed and any other relevant information.

Clinical Information

Physical health problems

Mental health problems

Other Agency Involvement

Organisation Name

Telephone

Address

Postcode

Agency Involvement

Support Needs

Advice Only

Primary Secondary Tertiary

Complementary Therapies

Primary Secondary Tertiary

Counselling

Primary Secondary Tertiary

Detoxification (Community)

Primary Secondary Tertiary

Detoxification (Inpatient)

Primary Secondary Tertiary

Family or Concerned Other Support

Primary Secondary Tertiary

General Support

Primary Secondary Tertiary

Holistic Social Packages of Care

Primary Secondary Tertiary

Out of work Service

Primary Secondary Tertiary

Rehabilitation

Primary Secondary Tertiary

Relapse Prevention

Primary Secondary Tertiary

Drink Wise, Age Well + Family Support

Primary Secondary Tertiary

Substitute Prescribing

Primary Secondary Tertiary

SORTED Young Persons service

Primary Secondary Tertiary

Mental Health

Primary Secondary Tertiary

Physical Health

Primary Secondary Tertiary

ABIS

Primary Secondary Tertiary

Alcohol Liaison

Primary Secondary Tertiary

PACT + PACT YP

Primary Secondary Tertiary

Moving on in my recovery

Primary Secondary Tertiary

Non Referral

Primary Secondary Tertiary

Appointment letter(s) sent

Yes No

Additional Information

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

Acknowledgement

The information provided above is accurate and the client is aware a referral is being made. I understand that DASPA will be in touch with the client to obtain further information and that this personal information could be shared with approved referral support organisations. All information will be stored in accordance with our privacy Policy and in line with the requirements set out by the general data protection regulation (GDPR) and the Data Protection Act 1998.