Direct Support

If you are looking for direct support and structured drug or alcohol treatment please complete the form below to make a referral.

Please note that the more information that is included on your referral, the quicker it will be processed. If too much information is missing from your referral we will need to call you to obtain this.

If you wish to download the referral form to send in via email or post Click here. Referrals should be sent to This email address is being protected from spambots. You need JavaScript enabled to view it. or your nearest GDAS base

Drug & Alcohol Service Referral

Service User Details

Name(*)

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Date of Birth(*)

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Nicknames - Alias

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First Line of Address(*)

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Postcode(*)

Invalid Input

Mobile(*)

Invalid Input

or Home Number

Other

Invalid Input

Email Address

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Details of PERSON MAKING REFERRAL (if different to above)

Name

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Mobile

Invalid Input

Agency

Invalid Input

Address

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

Other

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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(*)

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DOB(*)

Invalid Input

Age(*)

Invalid Input

Who do they live with(*)

Invalid Input

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

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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

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Accommodation(*)

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

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Other Accommodation

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Armed Forces - current or prior

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How is drug and or alcohol use affecting you

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What type of treatment or service are you seeking

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Primary Substance:

Name of Drug(*)

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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

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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

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

Health

GP Name and Practice(*)

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Is your GP currently aware of your drug or alcohol use

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NHS Number

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(if known)

Do you have any current physical or mental health concerns

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If yes please give details:

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

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

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(if yes please give details)

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

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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(*)

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(Hep B, Hep C, HIV, STI’s)?

Do you have a prenoxad kit

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(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

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Offence date - details

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(offence within the past 6 months for CJ Criteria)

Order start date

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Order end date

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Case admin

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Date of requirement

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Date referral sent

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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

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(please give details)

Do you feel anyone would consider themselves at risk from you

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

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

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Any further Risk information regarding self or to others

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Emergency Contact/Next of Kin

Name

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Relationship

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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

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