Referral Form - Gloucester House

Client's Personal Details

Name*

Address*

Phone*

Email*

NI*

Date*

Age*

Employed*

Yes
No

Benefits

If you receive any benefits, please enter what type of benefit and the amount you receive

Sanctions

What's your gender?*

Male
Female

Have you ever served in the United Kingdom HM Forces, or any other forces overseas?

Army
Air Force
Navy
MOD

Ethnicity*

Referrer's details

Name*

Number*

Email*

Substance Misuse History

Please list what drugs you are currently using, or have used in the past:

Alcohol

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Cannabis

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Heroin

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Crack

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Cocaine

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Amphetamines

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Benzodiazepines

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Solvents

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Methadone/Subutex

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Prescription/Over the Counter Drugs

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Legal Highs/Spice

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Gambling, Social Media, Sex, Gaming

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Have you ever injected drugs?*

Yes
No

When did you last have a blood test for HIV/Hep C?*

Result:*

Have you had a Hep B Vaccination?*

Yes
No

If yes to the above, what date did you have it?

If admitted to the centre would you want to be offered a Hep B Vaccination?*

Yes
No

Previous Treatment History and Health Information

History of help and engagement with previous treatment

Physical Health

Do you have any physical health issues?*

Yes
No

Please give details*

Do you have any known allergies?*

Yes
No

Please give details*

Do you consider yourself to have a disability?*

Yes
No

Please give details*

Are you receiving or due to receive any treatment for any health issues?*

Yes
No

Please give details*

Do you have a history of fits/seizures, and if so how often?*

Yes
No

Please give details*

Do you have, or have you ever had a DVT?*

Yes
No

Please provide the date*

Mental Health

Have you ever been diagnosed with any mental health problems, i.e. depression or anxiety?*

Yes
No

Please give details*

Is there a history of any mental health problems in your family?*

Yes
No

Please give details*

Have you ever experienced any hallucinations/psychosis?*

Yes
No

Please give details*

Are you currently engaged with the mental health services?*

Yes
No

Please give details*

Do you have a history of self harm or suicide?*

Yes
No

Please give details*

Medication currently prescribed

Medication

Being taken for

Dosage

Medication

Being taken for

Dosage

Medication

Being taken for

Dosage

Medication

Being taken for

Dosage

Please Note: if you are prescribed Gabapentin or Pregabalin, you must state who prescribed them and what for reason they were prescribed. Gloucester House does have a policy of working with clients and referring prescribers to reduce this medication and look at alternative options. If you have any questions in regards to this please call Rosaline Rolfe-referrals manager, or Chris Brockbank-medication lead on 01793 762365, or email me on [email protected]

Criminal History

Any incident of assault, wounding, ABH, GBH, affray or other violent crime?*

Yes
No

Please provide the date*

Please give details*

Any sexual offences?*

Yes
No

Please provide the date*

Please give details*

Any offences against children?*

Yes
No

Please provide the date*

Please give details*

Any incidents of arson?*

Yes
No

Please provide the date*

Please give details*

Do you have any court cases outstanding?*

Yes
No

Please provide the date*

Please give details*

Are you on a probation order?*

Yes
No

Please provide the date*

Please give details*

Are you on Licence/MAPPA?*

Yes
No

Please provide the date*

Please give details*

Have you ever been in prison?*

Yes
No

Please provide the date*

Please give details*

Do you have any outstanding fines?*

Yes
No

Please provide the date*

Please give details*

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