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

Agreement

Disclaimer AgreedPlease 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

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

Name of Referrer

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

Third Party Name / Organisation

Telephone

Address

Postcode

Additional Information

Client Information

First Name

Last Name

Nickname

Gender

DOB

Age

under 18

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

Yes No

NHS Number

Address

If NFA provide letter only address here.

Area

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

If Amphetamine, is it Daily or Recreational Use

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

Transitional Service

Is this person 18-25 years

Any further Information

IVDU

IVDU: Do you ever inject

Currently Injecting Previously Injected Never Injected Unknown

IVDU: Have you ever shared?

Yes No Unknown

BLOOD BORNE VIRUS' (BBV)

Have you been screened?

Yes No Unknown

Date Screened

If no, would you like to be screened

Yes NoIf yes, discuss BBV screening process.

Engagement Service

Support Needs

Brief Interventions Screening and Assessment Advice and Information sessions Unsure of Support NeedsPlease highlight any support needs to identify referral to Engagement Team

ABIS audit

How often do you have a drink containing alcohol

Typical units in a day when you are drinking

(ABIS Audit)

Unit Measurements

(Audit) How often have you have 6 or more units (female) 8 (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

Young Persons service- Barod

Primary Secondary Tertiary

Mental Health

Primary Secondary Tertiary

Physical Health

Primary Secondary Tertiary

Alcohol Liaison

Primary Secondary Tertiary

Engagement Team

Primary Secondary Tertiary

Recovery

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)

Service User Support Needs / Requirements

DASPA LOG NUMBER:

DASPA Terms

Acknowledgement

The information provided above is accurate and the client is aware a referral is being made. I understand 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.