Bridge Substance Misuse Programme
63c Gold Street
Northampton NN1 1RA
REFERRER DETAILS

I am referring myself (please leave the rest of this box blank)

I am referring someone else (please fill in the rest of this box)
Referring agency:
Referrer name:
Phone:
Email:
PERSONAL DETAILS
First names:
Surname:
Address:
Post code:
Date of birth:
Landline phone:
Mobile phone:
Gender at birth:

Male

Female
DOCTOR
GP’s name:
Surgery name:
Surgery address:
Surgery phone:
Smoking status  Currently smoking
Weight problem?
Ex-forces?


No

Previously smoked
No weight problem

Overweight
Air Force

Army

BF 001 Referral Form (version June 2016)



Marines
Never smoked
Underweight

Navy
Page 1 of 4
CRIMINAL OFFENCES
Current offences (the sentence is still in effect) OR current crime involvement:
Offending history (the sentence is over ):
Probation officer:
SUBSTANCE USE
Substance use (history)
Drugs:  (please specify below)
Alcohol: 
Substance use (current)
Drugs:  (please specify below)
Alcohol: 
Main Substance (the one substance
which is the biggest problem)
Primary
substance route
Main substance
(one substance
only please):
Age first used
Main substance:

Inject

Oral

Sniff

Smoke

Other
Injection status
Second substance
(one substance only please,
if none please write none):
Third substance
(one substance only please,
if none please write none):
Other substances (any number):

Never injected

Previously injected
(but not currently)

Currently injecting

Declined to answer
Injected in last 28 days?

Yes

No
Ever shared needles?
BF 001 Referral Form (version June 2016)

Yes

No
Page 2 of 4
ACCOMMODATION
Accommodation  No housing problem
need
 Housing problem

NFA - urgent housing
problem
Accommodation  NFA (no fixed address)
type
 Hostel

Long term sick or disabled

Not receiving benefits

Pupil/student

Regular employment

Retired from paid work

Unemployed and seeking work

Unpaid voluntary work

Other

Owned property

Rented

Settled

Supported housing
If not in work, out of work for how long?

Temporary

Less than 12 months

Traveller

12 months or more
CHILDREN
 Not a parent
Number of children living with client:

All of the children live with the client

Some of the children live with the client

None of the children live with the client

Client declined to answer
Pregnant?
EMPLOYMENT
 Homemaker

No

Yes
If yes, due date:
MENTAL HEALTH DIAGNOSIS

Undisclosed number

Client declined to answer
Are any of the children living with the client...
 A child looked after or in foster care

Subject to a child protection plan

Both

Neither

Client declined to answer
DISABILITY

None

None

Bipolar effective disorder

Hearing impairment

Borderline personality disorder

Learning disability

Cognitive impairment

Mental health condition

Depression

Physical impairment

Learning disability

Visual impairment

Personality disorder


Post traumatic stress disorder

Psychosis

Schizo affective disorder

Schizophrenia
Other (please specify):
Other disability:
Other mental health diagnosis:
BF 001 Referral Form (version June 2016)
Page 3 of 4
ETHNIC ORIGIN
White

White British

White Irish

Other white
Mixed

White and Asian

White and black African

White and black Caribbean

Other mixed
Asian or Asian British

Bangladeshi

Chinese

Indian

Pakistani

Other Asian
Black or Black British

African

Caribbean

Other black
Nationality at birth:
NEEDS AND INTERESTS

Mentoring

Women’s group

Men’s group

Acupuncture

Art expression

Meditation

Reflexology

Reading and writing help
Other

Other ethnic group

Not stated

Allotment

Boxercise

Circuit training

Football

Gym

Table tennis
Other needs and interests:
Any other information:
Referrer’s
signature:
Date :
OFFICE USE ONLY
 Client dropped in and completed a self referral form.
Date: __________ Time: _________ Duration: __________ Personnel: _________________

Referrer brought in a filled-in referral form.
Date: __________ Time: _________ Duration: __________ Personnel: _________________

Referrer sent in filled-in referral form. Date received: __________

Filled in at induction.
BF 001 Referral Form (version June 2016)
Page 4 of 4