RHEST Referral Form

Details of the person using the service

Name *

Alias

D.O.B

Age *

Gender *

Sexual Orientation

Address

Postcode

Lives alone

Yes

Rough Sleeper

Hostel

Sofa Surfing

Other

Borough Connection

If other, please specify

Next of Kin

Name *

Relationship *

Address

Postcode *

Telephone Number *

Other form of contact

Interpreter needed?

Yes

Ethnicity

White Background

White British

White Irish

White Gypsy or Roma or Traveller or Irish Traveller

White Other

Mixed Background

White & Black Caribbean

White & Black African

White & Asian

Other Mixed

Asian/Asian British

Indian

Pakistani

Bangladeshi

Other Asian

Black/Black British

Caribbean

African

Other Black

Other Ethnic Backgrounds

Chinese

Other

Not Stated

Religion

Baha’i

Buddhism

Christianity

Hinduism

Jainism

Judaism

Muslim

Pagan

Rastafarian

Sikhism

Zoroastrianism

Other Religion

No Religion

Not Stated

Referring Team

Name *

Address

Postcode *

Name of the referrer *

Lead contact(s) during engagement *

Telephone

Mobile

Email *

CHAIN number of client if applicable

Substance use history

Please list all substances used

Substance(s)

Route(s)

Average Daily Amount(s)

Are they currently injecting?

Yes

How has their drug use/drinking behaviour impacted on their health and wellbeing?

Are they already engaged with a Drug and Alcohol Service? Which service? Previous History of engagement with Substance Use Services?

Health Details

Current GP practice

Address

Postcode

Phone Number

Outline of Physical health issues below- Inc. diagnosis, treatment/medication

Risk Assessment

Please complete below or include the most recent (within 3 months) risk assessment as an attachment

Previous deliberate self-harm

Yes

Previous suicide attempts/ overdoses

Yes

N/K

Current suicidal ideation/ low affect

Yes

Significant past history of violence

Yes

N/K

Current thoughts/plans indication a risk of violence

Yes

Past history of arson

Yes

N/K

Involvement in high-risk sexual behaviour

Yes

N/K

Has serious physical health issues or unmet needs

Yes

Contact with Social Services or Children’s Services

Yes

Forensic history/current involvement with Justice System

Yes

Sexual offences or inappropriate sexual behaviour

Yes

Any other risks or concerns

Yes

Please specify any other risks or concerns

Childcare and dependents

Does the person have responsibility for children < 18 years old

Yes

Please specify

Person using the service consent

I confirm that the reasons for my referral to have clearly been explained

Yes

I understand that the information collected about me will be used to support care planning

Yes

I confirm that my care can be discussed with my partner, friends or family

Yes

Submit

Please submit this form or call 020 3745 0363 if you have any further questions

Please fill in the RHEST Referral form below

Elibility Criteria