Referral Form

Referral / Self Registration into Specialist Services

Are you making this referral on behalf of someone else?yes, I am making the referral on behalf of someone elseno, I am referring myself

Referrer Name

Agency Name

Phone Number

Email Address

Client has given consentYesNo

Client Details

Client Name *

Date Of Birth *

Street Address *

City

ZIP / Postal Code

Email Address *

Contact Number *

Preferred Way to be Contacted

PostSMSTelephoneEmail

I consent to referral to Horizon drug and alcohol service *YesNo

GP Details

GP Name *

Gp Address *

Additional Information

Main substance of misuse

Quantity of substance used?

PregnantYesNo

Domestic ViolenceYesNoHave you had any involvement in domestic violence now or in the past?

Mental Health Conditions / SymptomsYesNo

Risk of self-harm or suicidal thoughtsYesNo

Alcohol more than 40 units dailyYesNofor example drinking 13 pints of strong lager, 3 bottles of red wine or a bottle of spirits

HallucinationsYesNothese can be visual (seeing things) or auditory (hearing things)

Injecting drug useYesNo

Physical health conditions/symptomsYesNo

SeizuresYesNo

Learning DisabilitiesYesNo

AggressionYesNo

ProbationYesNo

Probation Officer Name

Adult Safeguarding, are you currently working with Adult Social Care?YesNoNot Stated

ASC Workers Name

Child Safeguarding, are there any children under the age of 18 in the household?YesNoNot Stated

Are you open to Children’s Services?YesNoNot Stated

Social Workers Name

Have you ever served in the armed forces?YesNoNot Stated

Consent to outreachYesNoA referral to the outreach team would be made if we were concerned about your welfare for example, we had not had any contact with you for a while. The outreach team are part of Horizon and come out to your home to do a check in.

Get In Touch

Talk to one of our friendly and professional experts today.

Call 012532051567 or email us on horizonreferrals@calico.org.uk. All enquires are handled with total confidentiality.

Contact

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