Recovery Online Professional Referral

Recovery Online Referral
Email Sender
Submission Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Referrer information
Referrer name

First NameLast Name
Role
Organisation
Phone Number
Format: (00000) 000-000.
Email

Client Information
What is your clients name?

First NameLast Name

Detox Requirement
Does {whatIs} require a detox before engaging with our National Recovery Online Programme?
Please indicate if this has been arranged with your service or does this need arranging with Clouds House?

Client Information
What was {whatIs} sex assigned at birth?
What does {whatIs} use to describe gender?
Religion
Does {whatIs} use pronouns?
Please select pronouns
Other
{whatIs}'s date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
{whatIs}'s ethnicity
{whatIs}'s preferred language
{whatIs}'s martial status
{whatIs}'s sexual orientation
{whatIs}'s Address

Street Address

Street Address Line 2

City / TownCounty

Post Code
{whatIs}'s telephone number
Format: (00000) 000-000.
{whatIs}'s Email

Agency Involvement
Is {whatIs} receiving support from another organisation such as social services, mental health service, criminal justice team, substance misuse team?
- Professional's name
- Agency
- Telephone number
  Format: (00000) 000-000.
- Professional's name
- Agency
- Telephone number
  Format: (00000) 000-000.
- Professional's name
- Agency
- Telephone number
  Format: (00000) 000-000.

Agency Involvement

Continued
Does {whatIs} have a care manager?
Care manager name
Organisation
Telephone number
Format: (00000) 000-000.

Medical
Is {whatIs} registered with a GP?
Doctor Name

First NameLast Name
Surgery
Surgery Address

Street Address

Street Address Line 2

City / TownCounty

Post Code
Telephone number
Format: (00000) 000-000.

What does {whatIs} want to achieve from doing this programme?
Does {whatIs}have any appointments or holidays booked in the next 6 months?
Please provide an overview of the appointments and/or holiday {whatIs} has booked?

Paying for treatment
Please let us know how {whatIs} treatment will be funded for Recovery Online
Please provide further information
How did you hear about Recovery Online?

Finally
Is there anything else that you would like us to know about {whatIs}?
Key Considerations: Risk to self, including self-harm or suicidal behaviours. Mental health conditions and physical health diagnoses. History of offending, including sexual offences or MAPPA status. Current probation or community orders. Domestic violence concerns or MARAC involvement. Involvement with social care services etc
Should be Empty: