N.B: When completing this form please ensure that all sections are completed and attach a recent risk assessment in ALL cases. Incomplete referrals may result in a delay in processing.
Date referral received / Referral No.Community Links Dual Diagnosis Referral Form
Personal DetailsName / Date of Birth
Previous Names
/ NI no.
Address:
Postcode / Contact telephone / Home No:
Mobile No:
Name and Relationship of Next of Kin / Contact Number
Residential status:
Owner occupier
Private rented
Living with friends/family
Council Tenant
Hostel / Homeless
Housing Association
Hospital
Secure Accommodation
Other (Please State)
______
Referral Details
Name of referrer: / Contact Numbers:
Email:
Team/Agency name and address
(if applicable)
Does the client know they are being referred to the service? / Yes / No
Have any other referrals been made for floating support or is the client awaiting a decision following a recent assessment from another agency?
Yes / No
If yes please specify below:
Please note that the Dual Diagnosis Service is funded by Supporting People (SP) and we are unable to work alongside another service funded in this way. To check if existing support is SP funded please go to:
Existing Support
If you have ticked any of the boxes below please provide details e.g. name, agency contact details
Carer/Family
Drugs/Alcohol Agency
Probation Officer
OT
CPN
/ Social Worker
Voluntary Organisation
Psychiatrist
Assertive Outreach Team
G.P.
Other please specify
If you have ticked any of the boxes above please provide details e.g. name, agency, contact details
Mental Health
Give details of the nature of the client’s Mental Health issues. Please include timescales, triggers and coping mechanisms.
Is the client currently being prescribed medication for Mental Health issues? If yes are any issues you are aware of or do they need any support in this area?
Please give details of any hospital admissions during the last two years. Also include the length of stay and number of admissions (were they voluntary or involuntary)
Physical Health
Is the client suffering from any physical health problems? Are they prescribed any medication for this? Please give details
Drug Use
Does the client use any drugs, either illicit or prescribed? If yes, please give details including the types of drugs, method of use, frequency and the length of time used
What effect does drug misuse have on their Mental Health?
Alcohol Misuse
Is problematic alcohol misuse an issue for the client? If yes please give details of level of consumption, history of use, impact on day to day living and relationships with others.
What effect does alcohol misuse have on their Mental Health?
Risk
Has any risks or concerns been identified in your work with this client? Please include self-harm or harm to others.
Does the client have a history of offending?
Does the client have any charges currently pending?
Does the client have children?
Are there any child protection issues that you are aware of?
Additional information
Is the referrer aware of/can they provide any reports or assessments pertinent to this referral? e.g. Risk Assessments, Probation Service Reports, Psychiatric Reports Yes / No
If yes, please give details below and attach copies if available
Is the client in employment/training?
If yes, please give details below (Part/full-time, training provider) / Yes / No
Is the client engaging in meaningful activity, voluntary work, leisure?
If yes, please give details below / Yes / No
Is the client in receipt of benefits?
If yes, please give details below / Yes / No
Support
What kind of support package does the client hope to receive from Dual Diagnosis?
Of the following areas, which does the client require support around? Please provide details.
Mental health issues
Finding and keeping housing and accommodation
Daily living
Child care or having access to see their children
Substance misuse
Finances, benefits or budgeting
Access to training, education and employment
Social interaction, leisure and building relationships
Cultural and/or faith issues
Access to health services/information
Anger management/ aggressive behaviour
Other (please state)
Additional Information
You can return this completed form to:
Community Links Dual Diagnosis Service
Unit 38
Batley Business Park
Technology Drive
Batley
WF17 6ER
Equal OpportunitiesPlease complete this section with the client you are referring. This information is stored separately and anonymously and is collated to ensure we continue to offer and improve an inclusive service to the community we serve.
How do you identify yourself (gender):(Please circle)
Male / Female
Do you live in the gender assigned to you at birth? (Please circle)
Yes / No / Did not want to state
How do you identify yourself (sexuality):(Please circle)
Lesbian / Gay / Heterosexual
Other / Bisexual / Did not want to state
What is your cultural background: (Please circle)
Does not want to state
White / Dual / Asian or British Asian / Black or Black British / Other Ethnic Group
British / White and Asian / Indian / Caribbean / Chinese
Irish / White and Black African / Pakistani / African / Gypsy/Traveller
Other / White and Black Caribbean / Bangladeshi / Other / Other
Other / Kashmiri
Other
Preferred Language:(Please circle)
European / Asian (Eastern) / Asian (Southern) / African / Middle Eastern and CIS
English / Cantonese / Bengali / Afrikaans / Arabic
French / Chinese / Hindi / Sudanese / Hebrew
German / Japanese / Punjabi / Russian
Hungarian / Sindhi / Other (please state)
Italian / Urdu
Polish
Spanish
Equal Opportunities (Cont)
What is your relationship status: (Please circle)
Married / Divorced / Other
Civil Partnership / Single / Does not want to state
What is your residency status: (Please circle)
British Citizen / Refugee / Other
Asylum Seeker / Destitute / Does not want to state
Do you have a physical disability:(Please circle)
Yes / No
What is your religion: (Please circle)
Christian / Buddhist / Hindu / Muslim
Jewish / Sikh / None
Other / Does not want to state
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Community Links – Dual Diagnosis Referral Form
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Community Links – Dual Diagnosis Referral Form