DASPA Form

Relevant paperworkIf you would like to upload any relevant paperwork ie assessment / risk assessment

Referral Acknowledgement

The information provided is accurate and the client is aware a referral is being made. I understand that this personal information could be shared with approved referral support organisations. All information will be stored in accordance with our privacy Policy and in line with the requirements set out by the general data protection regulation (GDPR) and the Data Protection Act 1998.

Would you like email confirmation?

If you need email confirmation that your referral has been successfully received then tick this box. Please note that the email will contain the last name of the referral and a unique Reference Number that we will use to refer to this person.

Full Name of ReferrerPlease ensure your name and contact information is correct in order so we can contact you if necessary.

What service area do you work in?

Organisation Name

Email

Telephone

Address

Postcode

Additional Information

First Name

Last Name

Nickname

Gender

Ethnicity

DOB

NHS Number

Address

Postcode

Area

Who do you live with

Are parent(s) / guardian(s) aware of referral

YesNoN/A

How can you be contacted?

Letter Telephone SMS Email

Which methods of contact are acceptable by the Service User?

Where would you prefer appointments?

Office Home Community

Where is the service user happy to have appointments? - Please tick all that apply

Telephone

Mobile

Email

Employment Status

Armed Services Veteran

YesNo

Dependant ChildrenAsk the SU the age, names and date of births and any additional information needed

Substance use issuesPlease give brief outline of substance use including quantity, route of use and how often.

Primary SubstanceIf no substance, add more information into notes above

Route

How Often

Amount

IVDU: Do you ever inject

Currently InjectingPreviously InjectedNever InjectedUnknown

IVDU: Have you ever shared?

YesNoUnknown

Where on your body do you normally inject

Age first used

Time Using

Prescribed

YesNo

Risk ManagementThink about risk of harm to self, risk of harm to others, any offences that have included violence, any risk of harm to lone workers? If none write N/A in box

Criminal Involvement

YesNo

Children Safeguarding Current involvement

YesNoUnsure

Child protection arrangementsIf none write N/A in box . Please give Social Worker name and involvement.

Adult Safeguarding Current Involvement

YesNo

Adult Safeguarding Arrangements

Cwm Taf GP

Bridgend GP

Are you pregnant

YesNoUnsure

Prescribed MedicationInclude reasons why this is being prescribed and any other relevant information.

Physical and/or mental health problems

Is this a Counselling referral

YesNo

Is this a referral for Concerned Other Counselling

YesNo

Please tick that criteria has been met.

The person has a Keyworker and will remain open to them while Counselling ongoing Has had 3 sessions or more with current worker Issues identified that require counselling Has not received counselling sessions via Barod in past 12 months

Please confirm all of these in order to confirm eligibility.

Please give brief overview of issues that require addressing Please indicate issues to be addressed eg: Bereavement, relationships, ACE's

Please choose the PRIMARY Support Need

Is this a Alcohol Liaison Referral

Yes

Please tick yes only if referring via Alcohol Liaison Nurse

Is this referral from VAWDASV Team?

Yes

MoCA Assessment required

Yes

Will you continue to work with this person?

YesNo

Please indicate yes or no and any relevant information in box provided below.

Service User Support Needs / RequirementsInclude here support needs and any information in relation to restrictions on contact ie text only or where the client would like appointments (home / office / community)

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