South Tyneside Recovery Service referral form

Are you making this referral for yourself or someone else?(Required)

Myself

Someone else

Is the person you are referring aware of the referral?

Yes

Name of the person being referred(Required)

First Middle Last

Preferred name of person being referred

Let us know if the person's preferred name is different to the name above.

Preferred pronouns

Date of birth of person being referred(Required)

NHS number (if known)

Gender at birth of person being referred(Required)

Male

Female

Prefer not to say

We are asking this so we can tailor support to the person's individual situation.

Gender identity

Same gender assigned at birth

Not the same gender assigned at birth

Not known

Prefer not to say

We are asking this so we can tailor support to the person's individual situation.

Do you have a fixed abode/address?(Required)

Yes

Does the person being referred have a fixed abode/address?(Required)

Yes

What type of address is this?(Required)

Home

Temporary

Correspondence only

What type of address is this?(Required)

Home

Temporary

Correspondence only

Address(Required)

Street Address Address Line 2 City County / region Post code

Address of the person being referred(Required)

Street Address Address Line 2 City County / region Post code

Primary phone number of the person being referred(Required)

Please provide a contact phone number, such as a home or mobile number so that we can get in touch.

Alternative phone number of the person being referred

Is there another number we can use in case we cannot get through on the primary phone number?

Email address of the person being referred

Preferred communication method(Required)

How would you like us to keep in touch with you? We will use your preferred communication to send you updates such as appointment reminders.

Preferred communication method

How would they like us to keep in touch with them? We will use their preferred communication to send them updates such as appointment reminders.

Main reason for referral(Required)

We need to know this information so we know what type of support you will need from us.

Second reason for referral(Required)

Let us know if you use another substance other than the one listed above. If you don't use a second substance, select "No second drug".

Third reason for referral(Required)

Let us know if you use a third substance other than the two listed above. If you don't use a third substance, select "No third drug".

Please provide some details about the substance use frequency and amount used(Required)

We ask this so we know what type of support we should be offering you.

What are your goals for support and/or treatment?(Required)

We ask this as everybody's goals are different and we can tailor support to what you want to achieve.

Preferred gender of your support worker(Required)

It may not be possible to assign you a worker of your preferred gender, but if you do have a preference please let us know.

Preferred gender of your support worker

It may not be possible to assign them a worker of their preferred gender, but if they do have a preference please let us know.

Do you have any communication needs?(Required)

Yes

We ask for this information so that we know how best we can communicate with you and if any extra assistance will be required.

Does the person have any communication needs?

Yes

We ask for this information so that we know how best we can communicate with the person being referred and if any extra assistance will be required.

Please tell us what communication needs you have(Required)

Hearing

Sight

Speech

Literacy

Translation

Other communication need

We will use this information to ensure our support considers how best we can communicate with you.

Please tell us what communication needs they have

Hearing

Sight

Speech

Literacy

Translation

Other communication need

We will use this information to ensure our support considers how best we can communicate with them.

Do you have any physical health or accessibility needs you would like us to consider?

We ask this question so that we can assess how best we can support any extra health needs you might have.

Do you have any mental health needs you would like us to consider?

We ask this question so that we can assess how best we can support any extra health needs you might have.

Please read the following privacy script and let us know when you've done so by checking the correct option. If you are referring someone else, this must have been read to them and understood.(Required)

This project is part of a charity called Waythrough. Our top priorities are your safety and helping you achieve your goals with us. To do this, we need to keep some information like your basic contact details and more sensitive information like your health details. This is called a “legitimate interest” to use your information. We keep your information safe and only share it with others if there is a good reason. Most of the time we ask your consent before we share, and we will complete our consent process with you during your first appointments with us. Occasionally, we may need to share your information without seeking your consent if we are worried that you or someone else could be in danger. This is called safeguarding and is a UK law that all health and social care organisations must follow. We will usually be able to tell you what we have shared and to whom. We will provide a factsheet with examples when we meet.

I HAVE read the above statement

I HAVE NOT read the above statement

Referrer name(Required)

First Last

Referrer organisation/source(Required)

Referrer email address(Required)

Referrer phone number(Required)

Is there any other relevant information you would like to tell us about the person you are referring?

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South Tyneside Recovery Service referral form

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