Herts adult & yp referral form

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This form is safe and secure. The information you provide is confidential and protected by encryption. We will only share information with professionals outside of Change Grow Live if we think someone is at risk of harm.

We will store this referral for a short time within the secure Formstack database. We will then keep it in our own storage. Only people who need to see the referral information will have access.

Please make sure you complete any questions marked with an asterisk (*) as we need these details to complete the next steps of your referral.

I am:*

referring myself a professional making a referral on behalf of someone else

Do you have consent from the person you are referring?*

Yes No

Does the person you are referring consent for us to update you on the outcome of the referral?*

Yes No

How old are you?*

25 or older Under 25

How old is the person you are referring?*

25 or older Under 25

Which hub would you like to refer to?*

Hatfield, Welwyn Garden City, St Albans and Borehamwood Hertford, Waltham Cross, Ware, Cheshunt and Bishops Stortford Stevenage, Letchworth, Hitchin, and Royston Watford, Hemel Hempstead, Tring and Berkhamsted Alcohol telecoms service (phone and video support only)

Please only complete a referral on someone's behalf if you have their consent. If you have any questions, please give us a call on 0800 652 3169 or email Herts@cgl.org.uk.

Full name*

First Name*

Last Name*

Date of birth*

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Day

Month

Year

Sex at birth*

Female Male I would prefer not to say

Your gender identity

We are asking these questions to make sure our service meets everyone's needs.

What do you use to describe your gender?

Female Male I prefer to self-describe

Self-description

Do you identify as trans?

Yes No Prefer not to say

What are your pronouns?

He/him She/her They/them Other pronouns Prefer not to say

Pronouns

Contact information

Do you have a fixed address?*

Yes No

Address*

Address Line 1

Address Line 2

City

Postcode

How would you like us to contact you? (Please choose all that apply)*

Email Phone Letter Home visit

Phone number*

Email address*

Confirm email address *

Please choose at least one option.

How we can help you

Please describe your drug and/or alcohol use *

What is the reason for your referral?*

Do you need any assistance? For example, you might need an interpreter or have a disability

Your patient or client's details

Full name*

First Name*

Last Name*

Date of birth*

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Day

Month

Year

Sex at birth*

Female Male They would prefer not to say

Gender identity

We are asking these questions to make sure our service meets everyone's needs.

What does your patient or client use to describe their gender?

Female Male Prefer to self-describe

Self-description

Does your patient or client identify as trans?

Yes No Prefer not to say

What are your patient or client's pronouns?

He/him She/her They/them Other pronouns Prefer not to say

Pronouns

Your patient or client's contact details

NHS number (if you have it)

Does your patient or client have a fixed address?*

Yes No

Address*

Address Line 1

Address Line 2

City

Postcode

How would your patient or client like us to contact them? (Please choose all that apply)*

Email Phone Letter Home visit

Phone number*

Email address*

Confirm email address *

Please choose at least one option.

How we can support them

Description of drug and/or alcohol use and reason for referral*

Alcohol AUDIT score

Any assistance needed (eg. translation or access needs)

Your details

Full name*

First Name*

Last Name*

Role

Agency or provider

Phone number*

Email address*

Confirm email address *

Full name*

First Name*

Last Name*

Date of birth*

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Day

Month

Year

Gender

Female Male I would prefer not to say I prefer to use my own term

What term do you use?

What is your ethnic group?

White Mixed or multiple ethnic groups Asian or Asian British Black, African, Carribean or Black British Other ethnic group Prefer not to say

Which of the following best describes your White background?

English, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White background Prefer not to say

Which of the following best describes your Mixed or Multiple ethnic groups background?

White and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic background Prefer not to say

Which of the following best describes your Asian or Asian British background?

Indian Pakistani Bangladeshi Chinese Any other Asian background Prefer not to say

Which of the following best describes your Black, African, Caribbean or Black British background?

African Caribbean Any other Black, African or Caribbean background Prefer not to say

Which of the following best describes your background?

Arab Any other ethnic group Prefer not to say

How would you describe your background?

Which country were you born in?

Country

Contact information

Current address*

Address Line 1

Address Line 2

City

Postcode

How would you like us to contact you? (Please choose all that apply)*

Letter Email Phone Home visit

Phone number*

Email address*

Confirm email address *

Do you need a translation service?*

Yes No

What is your main language?

How we can help you

What support would you like from the service?*

More information on drugs and/or alcohol To reduce or stop my drug and/or alcohol use Support regarding a family member’s drug and/or alcohol use Support regarding a friend's drug and/or alcohol use I’m not sure yet – I’d just like to speak to a member of your team

Other: Other Value

Is there anything else you'd like to tell us?

Your details

Full name*

First Name*

Last Name*

What is your relationship to the young person?*

Parent Carer Professional

Other: Other Value

Job title*

Agency / organisation*

Phone number*

Email address*

Confirm email address *

Does the young person’s parent(s)/carer(s) know about this referral?*

Yes No Unsure

Would you like feedback on the outcome of this referral?

Yes No

Other agencies

Are you aware of any other agencies working with the young person?

Yes No

Please provide details of these agencies below, and include as many details as possible.

If the young person is involved with social care, please specify the type of support.

Substance use

Which substance(s) is the young person is using?*

How frequently are they using?

Please provide any other information on the reason for this referral.

Risks

Other than the substance use, do you feel this young person is at risk of harm from themselves?*

Yes No I'm not sure

Please provide more information.*

Do you feel the young person is at risk of harm from others?*

Yes No I'm not sure

Please provide more information.*

Do you feel the young person may pose a risk to others?*

Yes No I'm not sure

Please provide more information.*

If you would like to provide any other information please include it here.

Young person's details

Full name*

First Name*

Last Name*

Date of birth*

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Day

Month

Year

Gender*

Female Male They prefer not to say They prefer to use their own term

What term does the young person use?*

Which country were they born in?

Country

What is their ethnic group?

White Mixed or multiple ethnic groups Asian or Asian British Black, African, Carribean or Black British Other ethnic group Prefer not to say

Which of the following best describes their White background?

English, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White background Prefer not to say

Which of the following best describes their Mixed or Multiple ethnic groups background?

White and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic background Prefer not to say

Which of the following best describes their Asian or Asian British background?

Indian Pakistani Bangladeshi Chinese Any other Asian background Prefer not to say

Which of the following best describes their Black, African, Caribbean or Black British background?

African Caribbean Any other Black, African or Caribbean background Prefer not to say

Which of the following best describes their background?

Arab Any other ethnic group Prefer not to say

How would they describe their background?

Address *

Address Line 1

Address Line 2

City

Postcode

How would your patient or client like us to contact them? (Please choose all that apply)*

Post Landline Mobile Email Home visit None

Other: Other Value

Landline number*

Mobile number*

Email address*

Confirm email address *

Is the young person attending school or college?

Yes No

What is the name of the school or college?

Does the young person give consent for us to contact their school or college?

Yes No

Is the young person pregnant?*

Yes No I'm not sure

Does the young person consider themselves to have a disability?

Yes No

Does the young person need an interpretor?

Yes No

What is their main language?