Cefnogaeth Uniongyrchol

Service User Details

Name(*)

Invalid Input

Date of Birth(*)

Invalid Input

Nicknames - Alias

Invalid Input

First Line of Address(*)

Invalid Input

Postcode(*)

Invalid Input

Mobile(*)

Invalid Input

or Home Number

Other

Invalid Input

Email Address

Invalid Input

Consent to contact with these methods

Invalid Input

Details of PERSON MAKING REFERRAL (if different to above)

Name

Invalid Input

Mobile

Invalid Input

Email

Invalid Input

Agency

Invalid Input

Address

Invalid Input

Has the individual consented to a referral to GDAS (*)

Yes No

Invalid Input

Socio-economic Details

Ethnicity(*)

Invalid Input

Primary Language(*)

Invalid Input

Welsh medium(*)

Invalid Input

Issues with literacy

Invalid Input

Disabilities or Neurodivergent conditions

Invalid Input

If yes please give details

Relationship status

Other

Invalid Input

Gender and Sexuality(*)

Invalid Input

Dependents or pregnant - please enter the information for each child

Do you have any children under the age of 18(*)

YesNo

Invalid Input

All About Me

Reason for referral:

Childs Name(*)

Invalid Input

DOB(*)

Invalid Input

Age(*)

Invalid Input

Who do they live with(*)

Invalid Input

Name of Social Worker - Please complete as Not Applicable against each child if appropriate(*)

Invalid Input

Do you currently live with anyone under the age of 18(*)

Invalid Input

Are you currently pregnant - if yes please confirm your expected due date(*)

Invalid Input

Are you responsible for any dependant adults(*)

Invalid Input

Employment Status(*)

Regular employment Pupil or StudentUnemployed (not seeking work)Unemployed (seeking work)Economically inactive (PIP, ESA, Retired, etc)Other (please give details)

Invalid Input

Other Employment Status

Invalid Input

Accommodation(*)

No fixed abode – lives on streets No fixed abode – sofa surfingSettled housingSupported HousingTemporary accommodation (please specify)Other (please give details).

Invalid Input

Other Accommodation

Invalid Input

Armed Forces - current or prior

Invalid Input

How is drug and or alcohol use affecting you

Invalid Input

What type of treatment or service are you seeking

Invalid Input

Primary Substance:

Name of Drug(*)

Invalid Input

How many days a week or a month do you use(*)

Invalid Input

How much do you use per day(*)

Invalid Input

How do you use(*)

Invalid Input

Orally, inject, sniff, etc.

Secondary Substance:

Name of Drug(*)

Invalid Input

How many days a week or a month do you use(*)

Invalid Input

How much do you use per day(*)

Invalid Input

How do you use(*)

Invalid Input

Orally, inject, sniff, etc.

Tertiary Substance

Name of Drug(*)

Invalid Input

How many days a week or a month do you use(*)

Invalid Input

How do you use(*)

Invalid Input

Orally, inject, sniff, etc.

Previous support for drugs - alcohol

Invalid Input

Do you feel there are any barriers which may prevent

Invalid Input

You from engaging fully with GDAS - please specify

Invalid Input

(Childcare, female/male worker, level & frequency of support)

How would you prefer your GDAS appointments to take place

Invalid Input

In person at a GDAS office / via video call / by phone/ via online courses / other (please specify):

Health

GP Name and Practice(*)

Invalid Input

Is your GP currently aware of your drug or alcohol use

Invalid Input

NHS Number

Invalid Input

(if known)

Do you have any current physical or mental health concerns

Invalid Input

If yes please give details:

To what extent would you say your mental health is affecting your day to day life

Invalid Input

Are you currently receiving support from Mental Health Services(*)

Invalid Input

(if yes please give details)

Are you currently having or have you ever experienced thoughts of suicide or self-harm(*)

Invalid Input

Please confirm any details of intentional overdose (approx dates, substance, were you admitted to hospital?)

Please confirm any details of accidental overdose (*)

Invalid Input

(approx dates, substance, were you admitted to hospital?)

Are you currently receiving treatment for any Blood Borne Viruses(*)

Invalid Input

(Hep B, Hep C, HIV, STI’s)?

Do you have a prenoxad kit

Invalid Input

(opiate use only) (Check in date)

Criminal Activity

How much do you use per day(*)

Invalid Input

Do you have any current - pending involvement with Crown or Magistrates Court - Police - Probation Service

Invalid Input

(if yes please give details)

Have you recently been released from prison

Invalid Input

CONTINUE TO RISK SECTION UNLESS CRIMINAL JUSTICE SERVICES – COMPLETE ADDITIONAL SECTION BELOW FOR CRIMINAL JUSTICE (Please do not use this form for DRR/ATR referrals)

Criminal Justice additional information

Offender Manager

Invalid Input

Offence date - details

Invalid Input

(offence within the past 6 months for CJ Criteria)

Order start date

Invalid Input

Order end date

Invalid Input

Case admin

Invalid Input

Date of requirement

Invalid Input

Date referral sent

Invalid Input

Type of order - supervision

RARSupervision OrderLicence/PSSSuspended Sentence / Community Order Invalid Input

(please tick)

Number of sessions required for RAR

Invalid Input

(if ticked above)

MAPPA Invalid Input

If yes - please give details

Invalid Input

MARAC Invalid Input

If yes - please give details

Invalid Input

IOM - WISDOM Invalid Input

If yes - please give details

Invalid Input

Short Term Sentencing Team (STST) Invalid Input

OASys information attached Invalid Input

(Please send with referral)

FOLLOWING SECTIONS TO BE COMPLETED BY ALL

Risks

Have you ever been a victim of domestic abuse - violence

Invalid Input

(please give details)

Do you feel anyone would consider themselves at risk from you

Invalid Input

Have you ever struggled to control your feelings of anger which has led to conflict in a relationship

Invalid Input

Would you be interested in receiving support with this in a group setting

Invalid Input

Any further Risk information regarding self or to others

Invalid Input

Emergency Contact/Next of Kin

Name

Invalid Input

Relationship

Invalid Input

Mobile

Invalid Input

Address

Invalid Input

Additional Notes

Please add any additional information which you feel may be relevant

Invalid Input

Drug & Alcohol Service Referral

Service User Details

Details of PERSON MAKING REFERRAL (if different to above)

Socio-economic Details

All About Me

Health

Criminal Activity

CONTINUE TO RISK SECTION UNLESS CRIMINAL JUSTICE SERVICES – COMPLETE ADDITIONAL SECTION BELOW FOR CRIMINAL JUSTICE (Please do not use this form for DRR/ATR referrals)

Criminal Justice additional information

FOLLOWING SECTIONS TO BE COMPLETED BY ALL

Risks

Emergency Contact/Next of Kin

Additional Notes

Error