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.

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DASPA Referral

Referrer Information

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.
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.

Living Arrangements

Substances

Please give brief outline of substance use including quantity, route of use and how often.

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
YESNOUNSURE Please complete this field
MANDATORY QUESTION **If none write N/A in box
YESNOPlease complete this field

Young People

Transitional Service

Peer Mentoring Under 25's

Please tick both for eligibility

Peer Mentoring 25 +

Please tick one that applies

IVDU

Prenoxad

BLOOD BORNE VIRUS' (BBV)

Engagement Service

Health Profile

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

Mental Health Liason

Community Drug and Alcohol Team (CDAT)

Counselling

Please confirm all of these in order to confirm eligibility.

RECOVERY

Other Service Involvement

Support Needs

Primaryincluding Reduction, Harm Reduction
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