Drug & Alcohol Single Point of Access
Authorised Access Only

Online DASPA Referral Form (TPN)

Welcome to the DASPA online referral form for professionals. By completing this form, you are confirming that the person being referred has consented and is aware of the referral being made. Please be as detailed as possible and ensure all details and support needs 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 or the person being referred. If this information cannot obtained, it may result in the referral not being actioned.

File Upload

If you would like to upload any relevant paperwork ie assessment / risk assessment

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.

DASPA Referral

Client Information


Please give brief outline of substance use including quantity, route of use and how often.
If no substance, add more information into notes above


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
If none write N/A in box . Please give Social Worker name and involvement.

Health Profile

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


Please confirm all of these in order to confirm eligibility.
Please indicate issues to be addressed eg: Bereavement, relationships, ACE's

Support Needs

Please tick yes only if referring via Alcohol Liaison Nurse
YesNoPlease indicate yes or no and any relevant information in box provided below.
Include here support needs and any information in relation to restrictions on contact ie text only or where the client would like appointments (home / office / community)

Joint Allocation Meeting - Admin use only

Barod Internal Referrals Only