Day Program Referral Form

Referrals are now open, please complete the form below

Client Name:

Client Email:

Client Phone:

Client Date of Birth

Client Address

Client Mobile

Client Gender

GP Name and Surgery

Referral Person

Referral Organisation

Referral Telephone number

Referral Email

Referral Date

Self Referral?

Probation Officer Name

Probation Officer Email

Probation Officer Telephone Number

Integrated Offender Manager Name

Integrated Offender Manager Email

Integrated Offender Manager Telephone Number

Has the client been diagnosed with MH issues or an illness?

Is the client on current medication? Please note medication, dosage and reason for being prescribed, and how long they have been taking?

Has the client achieved complete abstinence from ALL mind altering substances and alcohol? How long have they been clean?

Does the client attend 12 steps Fellowship meetings? NA, AA, CA?

Has the client attended recovery support services in the past? How long for? Please note previous treatment experience.

Is the client currently in Prison? If yes, what were they convicted for? what length of sentence? when are they due for release?

Does the client have a disability? If yes, what support will be needed?

Has the client ever been convicted of Arson?

Has the client ever been convicted of a sexual offence?

Has the client ever been convicted of a violent offence?

Has the client been on an ACCT whilst in prison? Please state the reason and how long for.

Will the client be subject to HDC that prevent evening fellowship and volunteering opportunities ?

Are there any dietary requirements?

Do you have any children? If yes , is there a care order?

What substances have you used in the past?

Are you in a relationship?

Do you have a religion? (this comes under are equality and diversity policies)

Are there areas of risk?

Registered Charity 1195424