Clouds House Referral Form

  • Clouds House Referral Form

  • Submission Date
     / /
  • Email Date Format
     / /
  • Are you completing this application on behalf of yourself?*
  • Who are you completing this application on behalf of?*

  • Information about you

  • What was your sex assigned at birth?
  • Date of birth*
     / /
  •  -
  • Format: (00000) 000-000.

  • About your addiction

  • What are you addicted to?*
  • What is your main addiction?*

  • How long do you consider you have had a problem with any of the addictive substances and/or behaviours listed above? 

  • Please select substances and/or behaviours you would like treatment for?*

  • About your addiction

    Continued

  • Alcohol

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  • What do you typically drink?*
  • Do you feel that your alcohol use is causing you problems?*
  • Do you feel you use alcohol too much or too often?*
  • Do you feel your alcohol use is out of control?*

  • Substances

  • Do you inject drugs?*
  • Have you injected drugs in the past?*
  • Have you ever shared equipment in the past?*
  • Are you currently on any Opiate Substitute Medication?*
  • Please select below*
  • Do you feel that your use is causing you problems?*
  • Do you feel you use too much or too often?*
  • Do you feel your use is out of control?*

  • Addictive Behaviour

  • Do you feel that your behaviour is causing you problems?*
  • Do you feel your addictive behaviour is out of control?*

  • Your family

  • Are you pregnant?*
  • What is your expected date of delivery?
     / /
  • Do you have any children under your care?*
  • Do you have any children under the age of 18 years old?*
  • Do you have any children over the age of 18 years old?*

  • About your medical history

  • We need to know what medication you are currently being prescribed. Please provide the following information of prescribed medication only. 

  • Are you currently receiving any medical care?*
  • Have you ever attempted to harm yourself?*
  • Have you / are you being treated for a mental health condition?*
  • Do you have any hearing, sight or mobility problems?*
  • Do you have any allergies?*
  • Do you have any infections that may be contagious?*
  • Are you waiting for any medical investigations, procedures or appointments?*
  • Do you have a GP?*
  • Format: (00000) 000-000.

  • About your relationship with food

  • Do you feel that your relationship with food is a problem for you?*
  • Have you been diagnosed with an eating disorder?*

  • If you are involved with other agencies

  • Are you receiving support from another organisation such as social services, mental health service, criminal justice team, substance misuse team?*
    • Please enter information below 
    • Format: (00000) 000-000.
    • Please enter information below 
    • Format: (00000) 000-000.
    • Please enter information below 
    • Format: (00000) 000-000.

  • If you are involved with other agencies

    Continued
  • Do you have a care manager?
  • Format: (00000) 000-000.

  • Legal

  • Premature discharge planning

  • In certain situations, you may choose to conclude your treatment before your initially scheduled completion date, or the treatment team may determine that continued treatment is no longer suitable, often due to the breach of essential safety requirements. Regardless of the circumstances, your safety is our foremost concern, and we need some information to create a "premature discharge plan."

  • Will you be returning to your home address?*

  • Please enter the address you plan to return to:

  • How will you get there?*

  • Who should be contact in inform that you are being discharged from Clouds House. 

    • Contact 1 
    • Format: (00000) 000-000.
    • Contact 2 
    • Format: (00000) 000-000.

  • Paying for treatment

  • If you require assistance arranging payment, please contact the Admissions Department at Clouds House and a member from the team will do their best to advise you. 

  • Please let us know how your treatment will be funded*

  • Finally

  • Should be Empty: