0330 303 6000

Client Details
Title:
☐Mr ☐Mrs ☐Miss ☐Ms
Other: / Name: / Referral Date:
D.o.B:
Address:
Postcode: / Gender:
☐Male ☐Female ☐Transgender
Other: / Telephone:
Mobile:
Email address:
Area of Residence: ☐Leicester City ☐Northwest Leicestershire ☐Harborough ☐Chamwood
☐Oadby / Wigston ☐Hinckley / Bosworth / Blaby ☐Melton ☐Rutland
Other:
Accommodation Status: ☐No Housing Problem ☐Housing Problems ☐Homeless
If Homeless, please advise how we can make contact, include Chain no. if known:
How would the client like to be contacted? ☐Phone ☐Text ☐Letter ☐e-mail
☐Other (please specify)
Ethnic / White: / Asian or Asian British: / Black/African/Caribbean/Black British:
Origin: / ☐British/English/Welsh/Scottish / ☐Indian / ☐Black African
☐Irish / ☐Pakistani / ☐Black Caribbean
☐Gypsy/Irish Traveller / ☐Bangladeshi / ☐Any Other Black Background
☐Any Other White Background / ☐Chinese
☐Any Other Asian Background / Other Ethnic Group:
Mixed: / ☐Arab
☐White & Black / ☐Any Other Ethnic Background
☐White & Black African / (please specify):
☐White & Asian
☐Any Other Mixed Background
Does the client require an interpreter? ☐Yes ☐No (If Yes, please specify language):
Does the client care for any children under 18? ☐Yes ☐No
Does the client consider themselves to have a disability? ☐Yes ☐No
(If Yes, please provide details):
GP Name and Address:
Does the client give consent for us to share information with the GP? ☐Yes ☐No
Referrer’s Details
Name: / Agency Name:
Address:
Postcode: / Telephone:
Fax:
Email:
Is the client aware of the referral? ☐Yes ☐No
Can we use your premises to conduct appointments with this client? ☐Yes ☐No
Would you like feedback on the outcome of this referral? ☐Yes ☐No
How did you hear about the Service?
Reason for the referral:
Alcohol Use:
Questions / Scoring System / Your Score
0 / 1 / 2 / 3 / 4
How often do you have a drink containing alcohol? / Never / Monthly or less / 2-4 times a month / 2-3 times a week / 4+ times a week
How many units of alcohol do you have on a typical day when you are drinking? / 1-2 / 3-4 / 5-6 / 7-9 / 10+
On a single occasion, how often have you had:
  • 6 or more units if you are female?
  • 8 or more units if you are male?
/ Never / Less Than Monthly / Monthly / Weekly / Daily or Almost Daily
NB: A total Score of 5+ indicates increasing/higher risk drinking YOUR TOTAL SCORE:
1 Unit of Alcohol / More than One Unit of Alcohol

Drug Use:
If Yes please specify:
Substance / Frequency of use / Method of Use
☐Benzodiazepine / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke☐Oral/Snort ☐Inject
☐Cannabis/Skunk / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐Cocaine / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐Crack Cocaine / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐Crystal Meth / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐Ecstasy / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐GHB / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐Heroin / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐Methadone / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐Novel Psychoactive
Substances / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
☐Steroids / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
Other (please specify): / ☐Daily ☐Weekly ☐Fortnightly ☐Monthly ☐Not Currently Using / ☐Smoke ☐Oral/Snort ☐Inject
How long has drinking and/or drug use been a problem (please specify weeks/months/years)?
Please list any medications and reason for taking them?
Risk and vulnerabilities:
Are there any risks that we should be aware of? ☐Yes ☐No
If Yes please provide details (e.g. alcohol/substance related, mental health, suicide/self-harm, risks from others, child safeguarding):
For referring agencies, please provide a current risk assessment: ☐Attached ☐Not attached
Criminal Justice Information (if relevant)
Order/Licence Type (please include any specific treatment requirements): / Offender Manager Name:
CRC ☐ NPS ☐
Contact Details (email/phone):
Current Prison (if relevant):
Statutory treatment start date/ release date:
Statutory treatment end date: / Integrated Offender Management
Priority IOM ☐
Enhanced IOM ☐
Not IOM ☐