Digital Referral Form

Digital Referral Form

Criminal Justice Referral Form

Thurrock Drug and Alcohol Service
Document Title
Referral Date

DayMonthYear
Email Address Sender FT
No Reply Email Address
Southend-on-Sea Email Address
Does your service user live within the Thurrock?

Support Services
Unfortunately, we can only work with individuals that live within Thurrock. If you are unsure what area you fall under, please enter your postcode into the Government Local Council website linked below. Please note that we only cover areas with a local authority of Southend-on-Sea Borough Council, or Southend-on-Sea City Council.

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

If your service user lives in a region of Essex; please contact Open Road at the link below.

Open Road Visions | Drug & Alcohol Recovery Service | Essex & Medway https://www.openroad.org.uk/
Contact Us - Open Road Visions

If your service user lives in a region of Rainham; please contact Turning Point at the link below

https://www.turning-point.co.uk/support-we-offer/drugs-and-alcohol

Otherwise, please contact us for more information.

Service User Name

First NameLast Name
Date of birth

DayMonthYear
Gender
Is the service user Pregnant?
Due date if known

MonthDayYear
Date
Does {serviceUser} have a fixed address?
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Telephone number
Email address
example@example.com
How can we contact {serviceUser} ? Please select all applicable.

Substance (s) requiring support?
Description of drug and/or alcohol use and reason for referral

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)

Other

Referrer Details
Referrer Name

First NameSurname
Is the referrer the managing officer for {serviceUser}?
Managing Officer Name

First NameSurname
Role
Organisation / Department
Telephone number
Email
Does {serviceUser} know you are making a referral to The Forward Trust?
Does {serviceUser} want to be referred to The Forward Trust?
Would you like to receive feedback on the outcome of this referral?

Supporting Documentation
Please upload any supporting documentation which may assist The Forward Trust with processing the referral to the secure upload below.

Supporting documents can include risk management plans, pre-setencing reports, previous offending information or medical information obtained from healthcare professionals.
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