Digital Referral Form

Self Referral Form
Document Title
Referral Date

DayMonthYear
Email Address Sender FT
No Reply Email
Which is your local Forward Trust service?*

Do you have a fixed address?*
If client is NFA, can you please specify the area where the client is residing in?*
What is your address?

Street Address

Street Address Line 2

TownCounty

Post Code
What is your telephone number?*
Do you have an email address?*
What is your email address?
example@example.com
How can we contact you? Please select all applicable*

TelephoneText messageLetterEmail
What is the name of your GP surgery?
NHS number (if known)

Have you had support from a drug and alcohol service before?*
Are you getting support from any other services?*
What support are you currently receiving? *
Do you take any prescribed medication?*
What medication are you currently taking?*

What substance(s) are you currently using and need support with?*
How much are you currently drinking or using?*

Neurodiversity
Does the client have or think they have a neurodiverse condition e.g. autism, ADHD, dyslexia?*

YesNo
If yes, please specify which neurodiversity condition(s)

ASD: Autism/Autistic Spectrum DisorderADHD: Attention Deficit Hyperactivity DisorderDyscalculiaDyslexiaDyspraxiaTourette’s SyndromeOther

Alcohol Use Disorders Identification Test

(AUDIT)
Based on your responses, we would suggest completing an Alcohol Use Disorders Identification Test (AUDIT). This is a simple and effective method of screening for unhealthy alcohol or identifying alcohol dependency.

The self identification tool is a 10 question test for assessing a person's level of alcohol risk and provides a framework for evaluating suitable interventions and treatment options.

Your results will be included in your treatment referral and will be discussed with you at your first appointment with The Forward Trust.
Would you like to complete an AUDIT which will be reviewed as part of your referral to The Forward Trust?*

Results

Alcohol Use Disorders Identification Test
Your score is:

{totalScore} - Lower Risk

Drinking at this level means that you are unlikely to be putting yourself at risk of alcohol-related harm.

Your results will be discussed with you during your first appointment with The Forward Trust.

Please proceed with completing your treatment referral.
Your score is:

{totalScore} - Increasing Risk

Drinking at this level increases the risk of damaging your health and could lead to serious medical conditions. Read here to better understand the risks.

Your results will be discussed with you during your first appointment with The Forward Trust.

Please proceed with completing your treatment referral.
Your score is:

{totalScore} - High Risk

Your score suggests that you are already finding that alcohol is getting in the way of your daily life and may be impacting on your health. You would benefit from making some changes to your drinking.

Your results will be discussed with you during your first appointment with The Forward Trust.

Please proceed with completing your treatment referral.
Your score is:

{totalScore} - Possible Dependence

Your drinking is already impacting on your health and wellbeing and you are at risk of alcohol dependence.

The higher your drinking score, the higher your risk. Find out more about the types of support that are available if you’re struggling to control your drinking.

You can also contact Drinkline for a free, confidential conversation on 0300 123 1110 (weekdays 9am – 8pm, weekends 11am – 4pm).

Your results will be discussed with you during your first appointment with The Forward Trust.

Please proceed with completing your treatment referral.

What goals can we help you with?*

What time of the day is best to contact you to discuss your treatment options?*

MorningAfternoonAnytime
Should be Empty:

Self Referral Form

Neurodiversity

Alcohol Use Disorders Identification Test

Alcohol Use Disorders Identification Test

Results