Professional Referral - Inclusion Hants

Has the client consented to this referral?*

Yes
No

Consent to contact by: Telephone/Mobile*

Yes
No

Consent to contact by letter:*

Yes
No

Can we say who we are by text or voice message:*

Yes
No

Consent to be contacted by a volunteer:*

Yes
No

Any disability requirements?*

Yes
No

Any literacy difficulties?*

Yes
No

Interpreter required?*

Yes
No

Referrer’s details

Your name (referrer):*

Your organisation:*

Job title:*

Contact number:*

Email address:*

Enter Email Confirm Email

Service user’s details

Forename:*

Surname:*

Gender:*

Male
Female

Date of birth:*

Address:

Street Address Address Line 2 City County / State / Region ZIP / Postal Code United Kingdom

NOTE: If NFA, ask ‘Are you in receipt of Benefits?’ If Yes, use address which they claim from.

Home number:

Mobile Number

Email address:

Enter Email Confirm Email

Consent to contact GP:*

Yes
No

GP Surgery address:*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Next of kin details

Name:*

Relation to client:*

Contact number:*

Service user's assessment

Alcohol use:*

Yes
No

Specify how much and how often:*

Please tick areas of concern:*

Physical health
Emotional health
Family
Relationships
Housing
Work
Employment
Finances
Illegal activities

Drug use:*

Yes
No

If you are completing this referral form for your own use, please select any of the substances used by you in the last 3 months

Please note, this does not include any drug prescribed to you by your doctor

Specify how much and how often:*

Please tick areas of concern:*

Physical health
Emotional health
Family
Relationships
Housing
Work
Employment
Finances
Illegal activities

Is client or partner pregnant:*

Yes
No

Due date:*

Current/history of mental health, and self-harm or suicidal thoughts/plans: Please specify*

Does client need to be seen by a male or female worker? Please specify*

Other service involvement (Social Care, probation, CMHT, Health Visitor): Please specify*

Criminal Justice (current or past cautions): Please specify*

Any children which may be in need/Risk: Please specify*

Physical health conditions or symptoms which are likely to require treatment: Please specify*

Client may present harm to self or others (threatening behaviour, verbal aggression, physical aggression): Please specify*

Pressing send on this form means you are giving your permission for Inclusion Hampshire to store the information you have provided and contact you in-line with Data Protection legislation. We will contact you on the phone number or email provided so we can determine how we can best support you in our service.