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Drug Referrals - Demo
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Drug Referrals - Demo
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Basic Details
First name (or pseudonym)
Surname
Gender
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Female
Male
Not Known
Not specified
Transgender
Date of birth
Please let us know the safest way to contact you, including the best time to make contact
Is it safe to leave messages?
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Yes
No
Don't Know
Please let us know why you are contacting us in as much detail as you feel comfortable with
Consent
I have read and agreed to the information sharing terms and conditions.
Yes
No
Referrer Details
Your name (referrer)
How do you know the person you are referring for support?
Referrer Agency/Organisation
Referrer Address 1
Referrer Address 2
Referrer Address 3
Referrer Address 4
Referrer Postcode
Referrer telephone number (landline)
Referrer mobile number
Referrer Email Address
Extra Referral Details
Ethnic origin of the person you are referring for support
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African
Any Other
Bangladeshi
Caribbean
Chinese
Ethnicity is unknown
Indian
Not Stated
Other Asian
Other Black
Other Mixed
Other White
Pakistani
White and Asian
White and Black African
White and Black Caribbean
White British
White Gypsy or Roma or Traveller or Irish Traveller
White Irish
Religion of the person you are referring for support
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Bahai
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Pagan
Sikh
Zoroastrian
Other
None
Declines to disclose
Religion unknown
How many children does the person you are referring for support have?
Is the person you are referring for support pregnant?
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Pregnancy: Further information
Does the person you are referring have any physical, learning or communication difficulties?
Does the person you are referring for support suffer from poor mental health?
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Is the person you are referring for support receiving support for their mental health problems? Please provide relevant details.
Does the person you are referring for support have any difficulties with alcohol use?
Does the person you are referring for support have any difficulties with drug use?
What is the relationship between the person you are referring for support and the person displaying abusive behaviour?
Choose...
I dont know
Partner
Ex Partner
Relative
Friend
Acquaintance
Stranger
Client (if related to sex work)
Trafficker
Do you believe that the person you are referring for support poses a risk to themselves?
Do you think that the person you are referring for support poses a risk to others?
What do you think the person you are referring for support is experiencing? If you are unsure, please use this field to explain what you think is happening to the person you are referring for support.
Is the person you are referring for support experiencing some kind of abuse now?
Yes
No
Does the person you are referring need support for abuse they have experienced in the past?
Yes
No
Is there any other relevant information that you can share with us, to help us support the person that you are referring?