DASPA
Secure Connection
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.
OFFICE USE ONLY
File Upload
If you would like to upload any relevant paperwork
DASPA Referral
Referrer Information
Agreement
Disclaimer Agreed
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.
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
Email
Telephone
Address
Postcode
Client Information
First Name
Last Name
Gender
Not Provided...
Male
Female
-
Agender
Androgyne
Androgynous
Bigender
Cis
Cis Man
Cis Woman
Gender Fluid
Gender Nonconforming
Gender Questioning
Gender Variant
Genderqueer
Intersex
Neutrois
Non-binary
Pangender
Transgender
Transgender (Man)
Transgender (Woman)
Transsexual
Transsexual (Man)
Transsexual (Woman)
Add New...
Ethnicity
Not Provided...
Asian British
Asian Other
Bangladeshi
Black African
Black British
Black Caribbean
Black Other
Chinese
Indian
Mixed Other/Multiple Ethnic Background
Not Stated
Pakistani
Polish
Portuguese
White Welsh
White British
White Irish
White Other
DOB
NHS Number
Address
If NFA provide letter only address here.
Area
Not Provided...
Rhondda
Cynon
Taff
Merthyr Tydfil
Out of Area
Postcode
Residency
Permanent
Temporary
NFA
Telephone
Mobile
Email
Preferred Contact
Telephone
Mobile
Post
Email
Living Arrangements
Who do you live with
Dependant Children
Substances
Substance misuse issues
Please give brief outline of substance use including quantity, route of use and how often.
Substance
Not Provided...
CONCERNED OTHER - NO SUBSTANCE
Alcohol
Cocaine
Heroin
Cannabis
Crack
Amphetamine
Valium/MSJ/Diazepam
NPS
Spice
Opiate Other
Ecstacy/MDMA
Methadone
Solvents
Tramadol
Pregablin
Gabapentin
Ketamin
Subutex
No Substance
Add New...
Risk Management
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
Children Safeguarding Current involvement
YES
NO
UNSURE
Please complete this field
Child protection arrangements
MANDATORY QUESTION **If none write N/A in box
Adult Safeguarding Current Involvement
YES
NO
Please complete this field
Adult Safeguarding Arrangements
Young People
Transitional Service
Is this person 18-25 years
Not Provided...
Yes
No
Please specify any relevant factors
16+ teams
Social Services
Supported housing
YOS
CAMHS
Youth Clubs
Learning Difficulties
Other
Peer Mentoring Under 25's
Is this person looking for support in accessing Education, Training, Employment or Volunteering
YES
NO
Eligibility for Peer Mentoring Service
Not in Education, Employment or Training
Experienced Substance Misuse and/or Mental Health (ie anxiety depression)
Please tick both for eligibility
Peer Mentoring 25 +
Is this person looking for support in accessing Education, Training, Employment or Volunteering
YES
NO
Eligibility for Peer Mentoring Service
Unemployed and been claiming Employment Support Allowance for 12 months plus
Unemployed and claiming Universal Credit - Sickness related (from day 1 can be referred)
One parent family claiming Universal Credit/Income support (from day 1)
Please tick one that applies
IVDU
Prenoxad
BLOOD BORNE VIRUS' (BBV)
Engagement Service
Health Profile
Registered GP
Not Provided...
Aberaman Surgery
Abercwmboi Medical Centre
Abercynon Health Centre
Ashgrove Surgery
Brookside Medical Centre
Calfaria Surgery
Castle View Surgery
Cwm Gwyrdd Medical Centre
Cwmaman Health Centre
Cynon Vale Medical Practice
De Winton Health Centre
Dowlais Medical Practice
Eglwysbach Surgery
Ferndale Medical Centre
Forest View Medical Centre
Foundry Town Clinic
Garth View Surgery
Gwaunmiskin Road Surgery
Health Centre University of South Wales
Hillcrest Medical Centre
Hirwaun Health Centre
Horeb Surgery
Maendy Place Surgery
Maerdy Surgery
Morlais Health Centre
New Tynewydd Surgery
Newpark Surgery
Oakland Surgery
Old School Surgery
Pant Surgery
Pantglas Surgery
Parc Canol Practice
Park Lane Surgery
Park Surgery
Penrhiwceiber Medical Centre
Penygraig Surgery
Pontcae Medical Practice
Pontnewydd Medical Centre
Porth Farm Surgery
Practice 1 Kier Hardie Health Park
Practice 2 Kier Hardie Health Park
Practice 3 Kier Hardie Health Park
Rhos House Surgery
Richards Stree Cilfynydd
SMSP
St Andrews Surgery
St Johns Medical Practice
Station Yard Pontypridd
Taff Vale Practice
Tegfryn Tonteg
The Health Centre Pontypridd
The Medical Centre Taffs Well
The Surgery Creigiau
The Surgery Elm Road
The Surgery Pontypridd
The Surgery St Davids Street
The Surgery Tonypandy (Llwynypia)
Treharris Primary Care Centre
Troed Y Fan Medical Practice
Tylorstown Surgery
Ynyshir Medical Centre
Ynysybwl Surgery
Are you pregnant
Yes
No
N/A
Prescribed Medication
Include reasons why this is being prescribed and any other relevant information.
Physical health problems
Mental health problems
Mental Health Liason
Community Drug and Alcohol Team (CDAT)
Counselling
Is this a Counselling referral
Yes
No
Please tick that criteria has been met.
The person has a Keyworker and will remain open to them while Counselling ongoing
Has had 3 sessions or more with current worker
Issues identified that require counselling
Has not received counselling sessions via Barod in past 12 months
Please confirm all of these in order to confirm eligibility.
Please give brief overview of issues that require addressing
RECOVERY
Other Service Involvement
Support Needs
Counselling
Primary
Detoxification
Primary
Family or Concerned Other Support
Primary
General support around substance use
Primary
including Reduction, Harm Reduction
Rehabilitation
Primary
Relapse Prevention
Primary
Substitute Prescribing
Primary
Young Persons service- Barod UNDER 18
Primary
Physical Health Assessment
Primary
Peer Mentoring
Primary
Service User Support Needs / Requirements
Include here any information in relation to restrictions on contact ie text only or where the client would like appointments (home / office / community)
Joint Allocation Meeting
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.
Would you like an Email Confirmation?
If you need email confirmation that your referral has been successfully received then tick this box. Please note that the email will contain the last name of the referral and a unique TPN Reference Number that we will use to refer to this person. This will also be provided on the next screen when you submit these details.