Reflections House Referral Form
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Personal Information
Full Name
Full Name is required.
Date of Birth
Date of Birth is required.
National Insurance Number
National Insurance Number is required.
Email
Email is required.
Phone
Phone is required.
Current Address
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Referral Information
Referral Name / Self Referral
Position
Agency Name
Agency Address
Telephone Number
Email Address
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Risk Assessment
Violence or Aggression
Arson or criminal damage
Self-harm/Suicide attempts
Poor or deteriorating physical health (self-neglect, poor hygiene, poor nutrition)
Poor or deteriorating mental health (is this alcohol or drug induced)
Domestic violence
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Support Needs
Mental Health
History of Drug Misuse
Ex or current offender
Learning Difficulties
History of alcohol misuse
Fleeing domestic violence
Rough sleeper
Traveller
Young person leaving care
Physical/sensory disability
HIV/AIDS
Hepatitis
Physical health needs
Medical Conditions
GP & GP Surgery Address
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Substance Dependency Issues
Substance dependency issues
Alcohol dependent
IV drug use now or in the past
On methadone program?
Completed detox program
Drug dependent
Linked to DIP or substance misuse team
Attending counselling or day program
Types of drugs tried or used in the past
Heroin
Cannabis
Methadone
Cocaine
Crack
Solvents
Amphetamines
Spice
Prescribed Medication
Ketamine
Subutex
Subutex Dosage
Methadone Dosage
Alcohol consumption levels
Any other information
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Benefits (Required)
Type of benefit received
Type of benefit received is required.
Benefit Amount
Benefit Amount is required.
Benefit claim started
Benefit claim started is required.
Next payment date
Next payment date is required.
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Address History
Previous address 1
Previous address 2
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Criminal Background
Has the client ever been convicted of a criminal offence?
Does the Client have any pending court cases? (If yes please give details)
Previous convictions
Is the Client on Probation/Licence?
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Dietary Requirements
Dietary Requirements
Life skills
Shopping:
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Cooking:
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Looking after money:
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Cleaning:
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Personal Hygiene:
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