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Devon Remote Referral
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Devon Remote Referral
Please use this form to provide your details (or details of the person you are referring for support)
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Referral Source
Name of Referrer
Referrer Service
Referrer Telephone
Referrer Email
Referrer Address
Is the client aware and consented to you making this referral?
Yes
No
Personal Details of the Individual Being Referred
First Name
Surname
Date of Birth
Address Line 1
Address Line 2
Town
County
Postcode
Home Telephone
Mobile Telephone
Email Address
NHS Number
Mobile
Yes
No
Voicemail
Yes
No
Text
Yes
No
Letter
Yes
No
Do they have any additional needs/special requirements?
Current Substance Use of Individual
What is their primary substance?
Choose...
Opiate
Non-Opiate
Alcohol
Alcohol & Non-Opiates
Please provide further details:
Physical Health
Do they have a physical health need?
Yes
No
Do they have a diagnosis from a doctor/consultant?
Yes
No
If yes to either of the above, please provide further details:
Are you registered disabled?
Yes
No
If yes to the above, please provide details:
Mental Health
Do you have a diagnosis from a Doctor/Consultant?
Yes
No
If yes to either of the above, please provide further details:
Children or Vulnerable Adults
Is the individual pregnant?
Yes
No
Do they have children?
Choose...
Yes
No
Declined to answer
If yes to any of the above, please provide further details:
Referral Summary
Brief summary of specific concerns/risks: