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

AREA OF REFERRAL

File Upload

If you would like to upload any relevant paperwork

BAROD INTERNAL REFERRALS ONLY - PLEASE JUST COMPLETE THIS SECTION

DASPA Referral

Is this referral for

Referrer Information

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.

Is this a Alcohol Liaison Referral

YES Please tick yes only if referring via Alcohol Liaison Nurse

Is this referral for

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

Client Information

First Name

Last Name

Gender

Ethnicity

DOB

NHS Number

Address

If NFA provide letter only address here.

Area

Postcode

Residency

Permanent Temporary NFA

Telephone

Mobile

Preferred Contact

Telephone Mobile Post Email

How would you like to conduct your support appointments?

Face to Face Online video call via Whatsapp/TEAMS/Zoom (please specify below) Telephone Blended (Please specify below) Other (please specify below)Please tick one that applies

Living Arrangements

Substances

Substance misuse issues

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

Substance

How Often

Amount

Substance

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

Children Safeguarding Current involvement

YES NO UNSURE Please complete this field

Child protection arrangements

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

Young People

Transitional Service

Peer Mentoring Under 25's

Peer Mentoring 25 +

IVDU

Prenoxad

BLOOD BORNE VIRUS' (BBV)

Engagement Service

Health Profile

Registered GP

Bridgend GP

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 monthsPlease confirm all of these in order to confirm eligibility.

Please give brief overview of issues that require addressing

Please indicate issues to be addressed eg: Bereavement, relationships, ACE's

RECOVERY

Is this person Abstinent and looking for Relapse Prevention Support

Yes No

Other Service Involvement

Support Needs

PLEASE TICK ONE ONLY

Counselling

Primary

Detoxification

Primary

Family or Concerned Other Support

Primary

General support around substance use

Primaryincluding Reduction, Harm Reduction

Rehabilitation

Primary

Relapse Prevention 1:1

Primary

Substitute Prescribing

Primary

Craving Meds

Primary

Young Persons service- Barod UNDER 18

Primary

Physical Health Assessment

Primary

Peer Mentoring

Primary

Will you continue to work with this person?

Yes NoPlease indicate yes or no and any relevant information in box provided below.

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 - Admin use only

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.