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Adolescent service partnership referral form
Adolescent service partnership referral form
Last Modified September 07, 2021
Download as PDF
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Referral summary
Date of referral
Name of referrer
First name
Last name
Role
Name of organisation
Address
Contact number
Email
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Consent
Has the young person/young adult given consent for this referral? (if No please seek consent prior to sharing information and referring).
Yes
No
Please provide the time and date that consent was verbally given
Are parent(s)/carer(s) aware of this referral and have they consented to information sharing?
Yes
No
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Young person's details
Name
First name
Last name
Gender
Date of birth
Age
If you are over 25 please contact Horizon www.horizonblackpool.uk
Ethnicity
Address
Address Line 1
Address Line 2
City
County
Postcode
Country
Telephone
Mobile
Email
Legal status
School/college
Communication needs/language
GP surgery and telephone number
Please let young people know the adolescent service will attempt to contact young people via all mediums available including telephone, email, home visits, Skype etc.
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Referral details
Reason for referral
Psychosocial, non-clinical support, for young people misusing substances* The team can facilitate access to clinical support including, prescribing, community and residential detox and rehabilitation.
Psychosocial, non-clinical support, for young people at risk of poor sexual health outcomes and in need of support with healthy relationships, contraception and or STI screening. The team can facilitate access to clinical support.
Please choose all that apply
Please give more details on your reasons for making this referral sexual health
Substance misuse details
Please add as much detail as possible
Heroin
Yes
No
Route
Please select
Smoke
Snort
Inject
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Crack
Yes
No
Route
Please select
Smoke
Snort
Inject
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Cocaine
Yes
No
Route
Please select
Smoke
Snort
Inject
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Other stimulant (i.e.) amphetamine
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Ketamine
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Cannabis
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Spice
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Benzos (Temazepam, diazepam etc.)
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Opiates (codeine, tramadol, fentanyl etc.)
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
GABAergic (gabapentin, pregablin)
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Alcohol
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Other substance
Yes
No
Route
Please select
Smoke
Snort
Inject
Swallow
Frequency of use
Please select
Daily
3 to 6 times a week
2 to 3 times a week
Occassionally
Amount
Are you working with any other agencies?
Please detail the agencies
Have you got any caring responsibilities?
Please give details
Have you got any other needs?
(physical, mental or learning)
Is there any additional information you feel is relevant?
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Privacy
Please ensure the following privacy statement is discussed with anyone named on this referral prior to submitting the referral.
By verbally consenting to this referral children’s cervices will record the information on the referral form on their database for between 24 months and 75 years depending on your status (for further information on your status please speak to a member of the team).
This information will also be shared with our adolescent service team who will contact you to explain the service that they offer and how this will help you. They will also explain what will happen with the information that you provide to them and how long they keep it for.
Blackpool Council's retention schedule https://www.blackpool.gov.uk/Your-Council/Transparency-and-open-data/Documents/Retention-schedules-2018/Childrens-Service-Retention-Schedule.pdf
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