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

Relevant paperwork:

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

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.

Please be aware we will attempt to make contact with the person referred within 3 working days of receiving this form. If we are unable to make contact then we will close down this referral. You can refer back into us via the website or 0300 333 0000:

I understand

Full Name of Referrer:

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

What service area do you work in?:

Organisation Name:

Email:

Telephone:

Address:

Postcode:

DASPA Referral

Is this referral for :

Cwm Taf Bridgend

Client Information

For self-referrals, please be aware we will attempt to contact you within 2 working days of receiving your form. If we are unable to make contact then we will close down this referral. You can refer back into us via the website or 0300 333 0000:

I understand

First Name:

Last Name:

Gender:

Ethnicity:

DOB:

NHS Number:

Address:

Postcode:

Area:

Telephone:

Mobile:

Email:

Prenoxad

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

Do you currently have any Domestic Abuse concerns or issues?:

Yes No

Domestic Abuse concerns or issues - Details:

Children Safeguarding Current involvement:

Yes No Unsure

Child protection arrangements:

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

Health Profile

Cwm Taf GP:

Bridgend GP:

Are you pregnant:

Yes No Unsure

Prescribed Medication:

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

Physical and/or mental health problems:

Counselling

Is this a Counselling referral:

Yes No

Has the pre-engagement information form been discussed with the service user?:

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

Support Needs

Please choose the PRIMARY Support Need:

Is this a Alcohol Liaison Referral:

YesPlease tick yes only if referring via Alcohol Liaison Nurse

Is this referral from VAWDASV Team?:

Yes

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 the full support needs of the client/what help are they seeking from the service.

Joint Allocation Meeting - Admin use only

Barod Internal Referrals Only

DASPA Terms

Acknowledgement

The information provided 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.

Online DASPA Referral Form (TPN)

File Upload

Referrer Information

DASPA Referral

Client Information

Substances

Prenoxad

Risk Management

Health Profile

Counselling

Support Needs

Joint Allocation Meeting - Admin use only

Barod Internal Referrals Only

DASPA Terms