Birmingham Referral Form

Swanswell

Referral form /

Swanswell is a national charity that helps people get on top ofdrug, alcohol and other problem behaviour so that they can change their lives for the better, feel well, do well and behappy.

We provide drug, alcohol and support services in different community based settings.

This form is to be completed when you or someone you know requires support from Swanswell.

For referrals sent from an organisation, Swanswell will require a copy of the:

· current in-date risk assessment

· current in-date care plan

· consent to share information document

· last completed assessment document

· completed referral form

To be completed by the person making the referral

Referral Source: (please tick one)

□ Self □ Organisation □ Family/Carers □ Dr. □ Other

If you’re making a referral on behalf of yourself, please tick ‘Self’. If you’re making the referral as a family member or carer, please state your relationship with the person for whom you’re supporting and your contact details in this box.

If you’re making the referral as part of a transfer from another organisation, please insert the name of the person making the referral, the agency in which you work, or the ward, department or the court you’re from in this box.

If the referral is part of a court order please stipulate the order details for example:

ROB, ATR, OSAP, DID, LIAP, Community Order, Licence, Supervision or Suspended Sentence.

Details about the person seeking a service from Swanswell

Title: (please tick one)
□ Mr □ Mrs □ Miss □ Ms □ Dr. □ Other
Name:
Date of birth:
Postal address:
Postcode:
City/Town: Contact number:
Country : Email:
Ethnicity: (please tick one)
□ White British
□ White Irish
□ White other
□ Mixed White and Black Caribbean
□ Mixed White and Black African
□ Mixed White and Asian
□ Mixed other
□ Asian British Indian / □ Asian British Pakistani
□ Asian British Bangladeshi
□ Asian British other
□ Black British Caribbean
□ Black British African
□ Black British other
□ Ethnic Chinese
□ Other (please specify)......
Reason for referral:
Please put the reason for making the referral to Swanswell in this box. Is it related to housing, drug or alcohol use, physical or mental health concerns, sexual wellbeing, family and friends support?
Please also include the current level of alcohol, drug use and the way the drugs are being used and any current health problems.
GP name and address:
Other agencies involved:
For example, supported housing provider, social services and health, probation, police, mental health services, hospital, employment services, counselling, drug or alcohol service, criminal justice service, court services.
Permission to share information: (please tick one)
□ Yes □ No
Please put who we can share information with for example, my mother, GP and referrer.
Preferred method of contact for the person seeking support: (please tick)
□ Letter □ Phone □ Mobile □ Email
Additional information:
Please put other any further information that could assist in the referral being processed.
Signature: / Date completed:

Swanswell – Referral form (W1) 1