Drug & Alcohol Referrals to Halo

First name of person being referred

Surname of person being referred

Date of birth

Gender

Telephone No.

Preferred contact method

Consent given to a home visit?

Yes

Address

Address 2

District

Town

County

Postcode

Mobile

Summarise drug and/or alcohol issues

Summarise Risks

Is there any childrens social care involvement (If yes please expand below)

Yes

Is there a housing issue (If yes please expand below)

Yes

Any other relevant information

Full Name

Referrer's phone number

Referrer's organisation

Referral date

Referred to Team

Fill in this form to refer your client to the appropriate team You MUST fill in all fields that are bold