CATCH 22 REFERRAL

If you used a downloadable PDF form, Please email the completed information to Wendy Coad, TCS Manager: sdaccouns@hotmail.com

Catch 22 Referral Form - Download for Manual Use

CATCH 22 REFERRAL (Automatic Send  Online Form:)



    GPSocial ServicesCMHRSSelfSDAC HelplineProbation NOMSProbation KCRA

    REFERRER INFORMATION:



    REFFERER CONTACT DETAILS




    YesNo

    How did you hear about us?

    - Self-referrals only


    CLIENT DETAILS













    MEDICAL Details





    YesNo

    CONTACT CONSENT


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    OUTLINE OF CURRENT SUBSTANCE MISUSE PROBLEM

    Please provide quantities/units of drugs or alcohol currently being used:


    HISTORY OF SUBSTANCE MISUSE AND PREVIOUS TREATMENT

    Have you previously received drug or alcohol treatment?


    YesNo

    If yes, please give an approximate date:


    PLEASE PROVIDE BRIEF DETAILS OF ANY OTHER MEDICAL OR MENTAL HEALTH PROBLEMS?

    Include any physical health conditions and if mental health problems ascertain CMHRS involvement:


    Is the person pregnant?


    YesNo

    If urgent out-of-hours support is needed, please contact the Mental Health Crisis Helpline on 0800 915 4644, open 24 hours a day, seven days a week.

    GP & HOSPITAL REFERRALS

    – Please attach a copy of the client’s medical history, recent prescriptions and recent blood test results to this referral:
    - Please inform us of any risks we should be aware of.


    This referral has been discussed with the client, and they consent to this information being shared with the Surrey and Borders Partnership NHS Foundation Trust i-access Community Drug & Alcohol Teams:


    YesNo

    *If this box is not marked “Yes” the referral process could be delayed as we may need to write to the client to ask if they would like an appointment with us.

    MANDATORY INFORMATION

    - We will be unable to process this referral until this information is provided
    - If alcohol is presenting problems please complete this AUDIT C Questionnaire

    How often do you have a drink containing alcohol?


    NeverMonthly or less2 - 4 times per month2 - 3 times per week4+ times per week

    How many units of alcohol do you drink on a typical day when you are drinking?


    1-23-45-67-910+

    How often have you had 6 or more units if you are female or 8 or more if you are male on a single occasion in the last year?


    NeverLess than monthlyMonthlyWeeklyDaily or almost daily

    Please ensure you have given the referee’s NHS Number and send this referral either: · By Email from a secure account to rxx.iaccess@nhs.net or from a non-secure account as a password-protected document.

    · By Post: i-access Admin Hub, Laurel House, Farnham Road Hospital, Guildford GU2 7LX

    · By Safe Haven Fax: 01483 302617

    · If you have any queries please call: 0300 222 5932

    Note 1: If the client is employed, is it safe to use mobile for initial contact during working hours? Or do they have a work number that counsellor can contact them on? Note 2: This question is asked to prepare the counsellor for someone else answering the phone instead of the client.