Smithfield Referral Form
Registered Manager
Louise Ford
[email protected]
Turning Point - Smithfield Detoxification Unit
Thompson Street
Collyhurst
Manchester, M4 5FY
0161 827 8588
Turning Point,
Standon House
1 Mansell Street
London, E1 8AA
020 7481 7600
www.turning-point.co.uk
Turning Point is a registered charity No. 23454565, a registered social landlord and a company limited by guarantee no. 793558 (England and Wales).
Please refer to the ‘Referral Guidelines Document’ for guidance and support on completing this Referral Form.
In addition please be aware that this referral will not be processed until:
Alcohol Clients


Recent (last 2 months) LFT’s including GGT, FBC and U and E’s have been taken and sent to us;
If the client is starting on Antabuse a recent ECG is required prior to admission.
Opiate Clients


If the client is starting on naltrexone LFTS are required prior to admission;
The most recent prescription of CD is sent to us or a copy of treatment plan.
All Clients


A transfer of care from GP is in place, summarising all medication and interventions provided by GP
Recent reports from Psychiatrists, CMHT, any specialist consultant/nurse, probation and other external
agencies are all in place.
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Date Referred
Click here to enter a date.
FOR OFFICE USE
TP Number
Date Received
New Client
Fax: 0161 827 8586
Email: [email protected]
Click here to enter a date.
Previous Inpatient
Personal Details
First Name
Surname
Date of Birth
Click here to enter a date.
Sex
Choose an item.
Tel
NHS Number
(If Known?
Mobile
Address
Postcode
NI Number
Consent
Choose an item.
Does the client consent to be contacted?
Choose an item.
If yes – how?
Local Authority
Local Authority (Please State):
DAT of Residence:
PCT of Residence:
Nationality
Ethnicity
GBR UK
IRL Ireland
IND India
NGA Nigeria
PAK Pakistan
White British
White & Black Caribbean
Other Mixed
Bangladeshi – Asian British
African – Black British
Other – Other ethnic
Ward of Residence:
White Irish
White & Black African
Indian – Asian British
Other Asian – Asian British
Other Black British
Not Stated
Other White
White & Asian
Pakistani – Asian British
Caribbean – Black British
Chinese – Other Ethnic
Refuge Asylum Seeker
Other (please
state):
If other ethnicity please give further details:
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Referrer Details
Referrer Name
Service
Address
Postcode
Tel
Choose an item.
Fax
Source of Referral
Other (please specify):
GP Name
Practice
Address
Postcode
Tel
Pharmacy
Fax
Frequency of Collection
Address
Postcode
Tel
Fax
Next of Kin
Contact Number
Emergency Contact
Contact Number
Address
Postcode
Tel
Mobile
4
Details of other people involved in clients care
To include: Probation, Social Services, Midwife, Prescriber, Health Visitor, District Nurse,
Housing Officer, Care Manager, Community Psychiatric Nurse, Key Worker, Dual Diagnosis, Any Other
Name
Profession/Relationship Contact Address
Contact Number
Fax Number
Client Risk Status
Are any of the following risk factors present? Yes
Client is Pregnant
Child Dependants
Lives Alone
Carer (for adult requiring specific needs)
Sex Worker
History of Seizures
Mental Health Issues/Concerns
Medical/Physical Health Concerns
Other (please state)
No
(If yes please mark with an ‘X’ all that apply)
Works whilst using drugs/drinking
Vulnerable to abuse by others
Poly-substance user
Threat to others
Homeless
Partner receiving treatment
Previous/current suicidal/self-harm ideation
IV drug-user /injects alone
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Current Medication
Current Medication
Current Medication
Dose
Prescribed
Prescriber
Is the medication
used as prescribed?
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
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Choose an item.
Allergies
Medication Allergies Yes
No
(please detail)
Other Allergies
No
(please detail)
Yes
TOPS
Has a TOPS form been completed? Yes
No
Date of most recent TOPs
Click here to enter a date.
Previous Withdrawal Symptoms
Seizures
Hallucinations
Anxiety
Panic attack
Diarrhoea
Constipation
Nausea/Vomiting
Retching
Sweats
Shakes/Tremors
Insomnia
Weight loss
Aches/pains
Restlessness
Agitation
Shivers/Chills
Stomach Cramps
Pounding Heart
Yawning
Sneezing
Running nose
Muscle Spasms/Twitches
Dilated pupils
Other
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Drug and Alcohol Use
Please complete all sections for each substance used by the client. Paying particular attention to substances used
in past 28 days.
Primary Problem(s) and Details
Substance
Alcohol
Primary
Substance
Used (in
order of
most
problematic
Route
1. Inject
2. Sniff
3. Smoke
4. Oral
5. Other
Frequency
1. Used
Daily
2. Used 2-6
per week
3. Used
once per
week or
less
4. Not used
in past
month
Quantity
Used e.g.
bags,
rocks,
grams
Prescribed
(tick if yes)
Duration of
Use (since
last period
of
abstinence)
Age
first
used
Significant
periods of
abstinence
Number of
drinking
days in last
4 weeks
Units per
day
Type of
alcohol
Amphetamine
Benzodiazepine
Cannabis
Cocaine
Crack Cocaine
Ecstasy
Heroin
Methadone
Other Opiates
Buprenorphine
Other (please
state)
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Treatment Options
Alcohol Detox
Stimulant Respite
Opiate Detox (using
Lofexidine)
Methadone Stabilisation
Methadone Detox
Benzodiazepine Detox
Buprenorphine Detox
Buprenorphine Stabilisation
Opiate Detox (using Buprenorphine)
Substance Misuse Treatment History
Treatment
Modality
Ever
Received
?
Treatment received for?
A. Opioid
B. Alcohol
C. Benzo
Where?
D. Amphet
E. Cocaine
Month/Year
of previous
treatment
Reason for leaving
treatment e.g.
Treatment Completed
Treatment Declined (by client)
Treatment Withdrawn
Moved Away
F. Poly
Inpatient/hospital
detoxification
Community
Detoxification
Specialist / GP
Prescribing
Structured Day
Programmes
Residential
Rehabilitation
Other (Please
state)
BBV History
Yes/No
Tested for HIV
Choose an
item.
Latest Test
Date
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enter a date.
Test Result
Injecting Status
Choose an
item.
Never
Injected
Currently
Injecting
Previously
Injected
Declined to Answer
Tested for Hep
A
Tested for Hep
B
Tested for Hep
C
Vaccinated
against Hep A
Previously
infected with
Hep B
Hep B
vaccination
Count
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an item.
Click here to
Choose an
enter a date.
item.
Click here to
Choose an
enter a date.
item.
Click here to
Choose an
enter a date.
item.
Click here to
Choose an
enter a date.
item.
Click here to enter a date.
Sharing
Ever Shared
Yes
No
Currently sharing
Equipment
Yes
No
Currently in
Treatment
Yes
No
Plans to go into
treatment
Yes
No
Hep C
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Physical and Psychological Health
Any Physical Health Problems/Concerns/Treatment Yes
(If yes please provide full details)
Seizures
Epilepsy
Diabetes
Other (please state):
No
Asthma
Heart Condition
Ulcers
Liver Condition
D.V.T
Pregnant
Further Details:
Detail any previous or current hospital treatment
Disability – Any disability? Yes
No
Behaviour and Emotional
Hearing Impairment
Manual Dexterity
Learning Disability
Mobility and Gross Motor
Perception of Physical
Danger
Speech Impairment
Personal, self-care and
continence
No Disability
Progressive conditions
and physical health
No Stated
Sight Impairment
Other (please state)
Detail any effect on daily living
Any Psychological Treatment/Concerns? Yes
No
(If yes please provide full details)
Include: diagnosis, concerns, treatment, history, psychiatric/Community Psychiatric Nurse involvement,
current/recent suicide/self-harm concerns. List any involved professionals under contacts (page 4)
9
Dual Diagnosis - Is the client currently receiving care from mental health services? Yes
Treatment Modality
Ever Received?
Currently in
Treatment? (state
where)
Month/Year
of previous
treatment
No
Reason for leaving
treatment e.g.
- Treatment completed
- Treatment Declined (by
client)
- Treatment Withdrawn
- Moved Away
Inpatient Mental
Health Treatment
Community Mental
Health Team
Detail any relevant reports, care plans or risk assessments to be faxed with this referral (with regards to
physical health, disability, psychological treatment or dual diagnosis)
10
Social Functioning
Accommodation
No Housing Problem
Lives Alone? Yes No
Housing Problem
(If No, detail with whom the client lives)
NFA – Urgent Housing Problem
Detail any housing issues and what plans are in place to address these (refer to page 15 to detail discharge plans)
Any Pets? Yes
No
(please detail arrangements)
Accommodation Status
Settled – LA/RSL
Rented
Settled – Private Rented
Temp – Direct
Access/Hostel
Settled – Other
(please state)
Settled – Own
Property
Settled – Supported
Housing/Hostel
Temp – Friends/Family
Temp – Other
(please state)
Relationship Status
Sexuality
Civil Partnership
Single
Heterosexual
Other
Separated
Divorced
Co-habiting
Married
Widow/er
Gay/Lesbian
Bi-sexual
Not Disclosed
Any relationship concerns? Yes
No
(If yes provide full details)
Details: domestic violence, exploitation/vulnerability, partner/friend, using drink/drugs, main carer for adult
dependants.
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Employment Status
Unemployed
Pupil/Student
Economically
Regular
Other
Inactive
Employment
Homemaker
Unpaid Voluntary
Long-term Sick or
Retired from paid
Work
disabled
work
If currently in employment, detail any arrangements that need to be made prior to treatment
Benefits
None
Disability Living Allowance
Income Support
Severe Disability Allowance
Child Benefit
Housing Benefit
Job Seekers Allowance
Statutory Sick Pay
Council Tax
Benefit
Incapacity Benefit
Pension Credit
Other
Any Financial Concerns? Yes
Any Children? Yes
Name of
Child
D.O.B
No
No
(If yes please provide full details)
(If yes please provide full details)
Male/Female
Relationship
to client
Contact
with
client?
(Y/N)
How
often?
Lives with
client? (Y/N)
If no, who
does the
child live
with? (Inc.
name &
relationship)
Name of
School
(Address if
known)
Name of
School
Nurse (If
under 5.
Name of
Health
Visitor)
Has a referral
been made
to School
Nurse/Health
Visitor? (Y/N)
12
Any previous/present involvement with Child Social Services? Yes
No
Do any child care arrangements need to be made prior to treatment? Yes
(If yes please provide full details)
(If yes please provide full details)
No
Criminal Involvement and Offending
Any Offending Risks? Yes
No
(If yes please provide full details)
Recent/Past
Serious violence towards others e.g. GBH, Choose an
Subject to Multi-Agency Public
ABH, fighting
item.
Protection Arrangements
Aggression without serious violence e.g.
Choose an
Risk to Property, including Arson
Threats, verbal aggression
item.
Client is known to possess dangerous
Choose an
Sexual Offence against Children
weapon(s) e.g. Firearm, knife
item.
Currently known to criminal justice
Choose an
Sexual Offence against Adult
services e.g. Probation
item.
Domestic violence (Perpetrator)
Choose an
Other (please state)
item.
Recent/Past
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
13
If any offending risks are ticked, please provide further details and send copies of any relevant reports and/or
assessments
Any current legal considerations? Yes
No (If yes please provide full details)
Subject to Bail
Outstanding Court matters
Outstanding Warrants
Community Rehabilitation Order
On Licence
Other (please specify)
DRR
Additional Information (If current probation involvement complete contact information on page 4)
Cultural and Spiritual
Are there any relevant cultural needs? Yes
No
(If yes please provide full details)
14
Language
Is English the first language?
Yes
No
Is an interpreter required?
Yes
No
If no, please state first language:
If required, please provide details of interpreter
Religion
Atheist/Agnostic
Christian
Jewish
Sikh
Baha’l
Hindu
Muslim
Zoroastrian
Buddhist
Jain
Pagan
No Religion
Other (please state)
Any specific dietary requirements? Yes
No
(If yes please provide full details)
E.g. Halal, Kosher, Vegetarian, Build-up Diet, Allergies/Intolerances
15
Discharge and Contingency Plans
Referrals (tick any referrals that have been made)
No onward
referral made
Referred to rehab
Referred to voluntary
services
Referred to care
management
Referred to structured
day care
Referred to
education/training/employment
Referred to
supported housing
Referred to support
groups/networks
Referred to social
support
Details of Discharge Plan
Detail of any professionals providing post-discharge support
Discharge Address (If different from Page 1)
Address
Postcode
Tel
Mobile
Contingency Plan if client discharges early
Consider: who to contact if discharged at weekend and provisional plans to ensure clients safety
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CONSENT FORM
The information you provide will be held by Turning Point and used by Turning Point for the purposes of providing
the support you need and ensuring the continuity of services provided to you.
Information you provide, may with your consent be shared with Public Health England (PHE), Local
Commissioners and/or Partner Agencies for the purposes of audit and performance monitoring and research.
Audit and research information is anonymised ensuring it is not possible to link data to particular individuals,
families or carers. Although the bare minimum of personal data is sent to PHE and this information is kept
confidential, it is possible for the service user to be identified by this information in a minority of cases.
Your information will not be used for any other purpose and will not be passed to any other third party without
your permission other than when Turning Point is required to share your information under other government
legislation. Records for individuals using our substance misuse services will be kept for 7 years after the
conclusion of treatment in accordance with PHE guidelines on Record Retention, unless locally determined record
retention periods are set.
I have been advised that I can withdraw my consent to this information being shared with Public Health
England, Local Commissioners and/or partner agencies at any time and that if I do not consent to my
information being shared with PHE , Local Commissioners and/or Partner Agencies it will not prevent me
getting the treatment I need.
I consent to my information being shared with Public Health England, Local Commissioners and/or Partner
Agencies.
Client Signature……………………………………………………………………………Date……………………………………………………………………
Worker Completing Form……………………………………………………………Date……………………………………………………………………
Having discussed my care and support programme with the person referring me to Smithfield, I give consent
to participate in the agreed programme and I understand that I can withdraw this consent at any time.
Client Signature……………………………………………………………………………Date……………………………………………………………………
Worker Completing Form……………………………………………………………Date…………………….………………………………………………
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Parent Agreement to Share Information
We are required to inform your child’s school nurse or health visitor that you are accessing treatment at our
service. This information will remain confidential to professionals involved in working with you and your children
and the children in your care and ensure they receive support as well as you.
We will only contact Social Services Child Protection Team if we believe your child is at risk of significant harm.
We understand that substance-misusing parents/carers are capable of caring for children.
I have read and understood the above statement
Client Signature……………………………………………………………………………Date……………………………………………………………………
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CONSENT FORM
Name:
D.O.B:
Address:
This is my consent for a Brief Medical Summary/Transfer of Care
Report. A copy of my current/acute prescriptions and any other
health information to be disclosed to the referrals and admissions
Team at Smithfield Service upon their request. This is to ensure that I
get correct and continued care.
Signed: _____________________ Date: _______________
Please fax to 0161 827 8586 or e-mail to [email protected]
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