Adfam Remote Rehab Service

This is a pilot project run collaboratively between Adfam and Lancashire Local Authority, supporting Families affected by a loved ones substance misuse which had led to rehab treatment.

Only professionals linked into the Lancashire adult substance misuse team should use this form for referrals.

Referrer

Referring organisation*

Referrer name*

Referrer phone number*

Referrer email address*

Has this individual agreed to support?*

Yes

Client

First name*

Last name*

Date of birth*

Gender*

Other gender

Contact details

Phone number*

We will only use this to contact the client about the service.

How can we use this phone number?

Text messages

Phone calls

Leave messages (voicemail)

Email address

We will only use this to get in touch about the referral.

Can we send emails?

Yes

Address*

Town*

Postcode*

Can we send letters to this address?

Yes

GP details

GP Practice Name*

GP Practice Address*

GP Practice Town*

GP Practice Postcode*

GP Practice Phone number*

Referral

Any known risk / safeguarding concerns within this family?*

Please detail if yes.

Please list names, organisations and contacts of any professionals engaged with the family.*

Has this person had any previous support relating to their situation as the loved one of someone who uses drugs and/or alcohol?*

Please give details.

Who is it that has the drug/alcohol problem?*

Please tick all that apply.

Mother

Father

Brother

Sister

Son

Daughter

Other family member

Partner

Friend

Other

Ex-partner

Other: please specify

Does the person with the drug / alcohol problem usually live with the client?*

Yes

Sometimes

Please list names and DOBs of all children (under 18s) living in the home or closely connected with the family, including step children living elsewhere or sometimes resident etc.*

Any known significant physical health problems or mental health problems?*

If yes, please detail.

Any known criminal justice involvement? (substance user and wider family)?*

If yes, please detail.

What substances does the substance using person within the family use?*

Please list all substances.

Does the individual (client) use any substances themselves? How would they describe any alcohol use?*