The Bridges Referral Form

The Bridges Referral Form
Submission Date

DayMonthYear

MinutesAM/PM Option
Email Date Format

DayMonthYear
Email Sender
Are you completing this application on behalf of yourself?*

YesNo
Who are you completing this application on behalf of?*

EmployeeFamily memberFriendPartnerPatient / Service User

Treatment needs
Which treatment package are you applying for?*

Stage 1 (12 weeks)Stage 1 & 2 (24 weeks)
Do you need assistance from our detox programme available at our affiliated facility, Clouds House?*

YesNo

Information about you
Name*

First NameLast Name
What was your sex assigned at birth?*

FemaleMaleI would prefer not to say
What do you use to describe your gender?*
Do you use pronouns?*
What are your pronouns?*
Other*
Date of birth*

DayMonthYear
National insurance number
Required for GP registration
Ethnicity*
Preferred language*
Martial status *
Sexual orientation*
Housing status*
Home Address*
Home telephone number

Area CodePhone Number
Mobile telephone number*
Format: (00000) 000-000.
Email

Employment situation
Are you currently employed?*

YesNo
Please select the most appropriate answer?*

EmployedSelf-employed
Please state what your occupation or business is below*
Please select the most appropriate answer?*

UnemployedHomemakerStudentRetired
How long have you been unemployed?*

Your family
Are you pregnant?*

YesNo
What is your expected date of delivery?

DayMonthYear
Do you have any children under your care?*

YesNo
Do you have any children under the age of 18 years old?*

YesNo
How many children do you have under the age of 18 years old? *
Do you have any children over the age of 18 years old?*

YesNo
How many children do you have over the age of 18 years old? *
How many children live with you?*

About your relationship with food
Do you feel that your relationship with food is a problem for you?*

YesNo
Please provide further information below*
Do you have any dietary requirements*

YesNo
Please provide further information below*
Have you been diagnosed with an eating disorder?*

YesNo
Who made the diagnosis? *

First NameLast Name
Contact details*

Offending history
Do you have a history of offending behaviour?*

YesNo
Please give details here of any offending history
Please attach additional supporting information. We may contact relevant local area probation services in support of your application

Cancelof

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?*

YesNoOther
Please enter the address you plan to return to:
Address

Street Address

Street Address Line 2

City / TownCounty

Post CodeCountry
How will you get there?*

Public transportFamily memberFriendTaxiOther
Who should be contact in inform that you are being discharged from The Bridges
- Name*
  
  First NameLast Name
- Telephone number*
  Format: (00000) 000-000.
- Name
  
  First NameLast Name
- Telephone number
  Format: (00000) 000-000.

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?*

YesNo
- Professional's name
  
  First NameLast Name
- Agency
- Telephone number
  Format: (00000) 000-000.
- Professional's name
  
  First NameLast Name
- Agency
- Telephone number
  Format: (00000) 000-000.
- Professional's name
  
  First NameLast Name
- Agency
- Telephone number
  Format: (00000) 000-000.

If you are involved with other agencies

Continued
Do you have a care manager?*

YesNo
Care manager name*

First NameLast Name
Organisation*
Telephone number*
Format: (00000) 000-000.

In your own words, why do you wish to enter residential rehabilitation treatment at this time?*

Declaration
This section must be signed by the applicant to give consent for The Forward Trust to progress the application. If not possible, then an additional/alternate consent document will be accepted.

I confirm that the information provided in this application is, to the best of my knowledge, true and accurate.

I consent to The Forward Trust, The Bridges – Hull and the National Probation Service sharing information between them relevant to my application and contacting any of the agencies listed in this application to obtain further information that may support my application.

If any information is withheld or falsified from this form I agree that any offer of treatment may be rescinded without notice.
Name

First NameLast Name
Signature*

Clear
Timestamp

DayMonthYear
Date
Hour MinutesAM/PM Option

Finally
Is there anything else that you would like us to know about you?
Should be Empty: