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Name of referrer*
Referrer contact no.*
Date of referral*
Service*
Referrer email address*
Name*
Pronouns*
Contact number*
First language*
Date of birth*
Address*
Email address*
Emergency contact*
Relationship*
Contact no.*
Please complete the below:
Does the client have a disability?
—Please choose an option—YesNoUnknown
Further details:
Is the client a veteran?
Does the client have any mental health needs?
Does the client have any substance or alcohol use?
Brief summary including risk details / substance mis-use.*
Is the client working with any other services? Please confirm and provide details where appropriate.
Service
Contact name and details
CGL Star
NoYes
Probation
Mental Health team (Sussex Partnership Trust)
Social Services
Treatment Services
Support Networks
Family / Next of kin
GP Practice
Other
Has the client been made aware of this referral?*
—Please choose an option—YesNo
If not, why not?
By Post* —Please choose an option—Consents to contactDoesn't consent to contactUnknown
By Phone* —Please choose an option—Consents to contactDoesn't consent to contactUnknown
By Email* —Please choose an option—Consents to contactDoesn't consent to contactUnknown
Disclosure/Consent
In order to help you access the most appropriate support, we would like to gather some basic information about you. This will consist of your name, date of birth, and a brief summary of your circumstances.
Other agencies also may have a duty to provide support for you under the Health and Social Care Act 2012 or under the Care Act 2014.
We would like your consent to share the information you give us with appropriate agencies.
If there is a concern about your safety, or the safety of others, we may need to share information without your consent. However, we will strive to inform you if this needs to happen beforehand. Please indicate where you consent for us to share information with the following agencies:
Agency Name
Consent to share information?*
Date consent given
Any limitations on consent? If yes, please provide details:
Seaview Services: Wellbeing Centre, RADAR, SASS, Specialist Outreach Recovery Service
STAR Alcohol and Drug Treatment Service
Adult Social Care
Sussex Police
Department of Work and Pension
Citizens Advice 1066
Adfam Carers Service
Housing Services
Rough Sleepers Initiative (RSI)
Family/Next of kin
Hospital/Emergency Services
Mental Health Team (Sussex Partnership Trust)
IC 24 Station Plaza walk in service
Other:
Please type your name as signature below
Client Signature*
Date:
Worker Signature*
By submitting the form above you consent to be contacted by Seaview Project using the details provided.
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