Digital Referral Form

  • Self Referral Form

  • Referral Date
     / /

  • Support Services

  • Unfortunately, we can only work with individuals that live within the Medway area. If your service user is unsure what area they fall under, please enter the postcode into the Government Local Council website linked below. Please note that we only cover areas with a local authority of Medway.

     

    https://www.gov.uk/find-local-council 

     

    Otherwise, please contact us for more information; medway.referrals@forwardtrust.org.uk 

  • What is your date of birth?*
     / /
  • What was your sex assigned at birth?*
  • What do you use to describe your gender?*
  • What are your pronouns?*
  • Where did you hear about us?*
  • How can we contact you? Please select all applicable*

  • Neurodiversity

  • Does the client have or think they have a neurodiverse condition e.g. autism, ADHD, dyslexia?*
  • If yes, please specify which neurodiversity condition(s)

  • 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 Medway RIVER Treatment & Recovery Service.  

  • Alcohol Use Disorders Identification Test

    (AUDIT)
  • How often do you have a drink containing alcohol?*
  • How many units of alcohol do you drink on a typical day when you are drinking?*
  • How often do you have 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
  • How often during the last year have you found that you were not able to stop drinking once you had started?*
  • How often during the last year have you failed to do what was normally expected from you because of your drinking?*
  • How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?*
  • How often during the last year have you had a feeling of guilt or remorse after drinking?*
  • How often during the last year have you been unable to remember what happened the night before?*
  • Have you or someone else been injured as a result of your drinking?*
  • Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?*

  • 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 Medway RIVER Treatment & Recovery Service.

     

    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 Medway RIVER Treatment & Recovery Service. 

     

    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 Medway RIVER Treatment & Recovery Service.

     

    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 Medway RIVER Treatment & Recovery Service.

     

    Please proceed with completing your treatment referral.

  • How often do you drink and/or use substances?*
  • How do you use?*
  • What time of the day is best to contact you to discuss your treatment options?*
  • Should be Empty: