Substance Misuse Referral Form for Professionals

 

Section A:

Details of young Person

Name  
Date of birth/age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Gender   MaleFemale

Ethnicity
Address (that SWITCH can write to)  
Telephone no. that SWITCH can use  

Name of education or training provision  
Telephone Number  

Name of Doctor  
Telephone  

Details of person completing screening tool and referral

Name & Position  
Organisation and Telephone number  
Referal E-mail  
Does the young person consent to this referral?

Section B

is injecting drugs
is using any Class A drug i.e. Heroin, Crack, Cocaine, Ecstasy
is misusing prescription drugs
is misusing anabolic steroids
reports any use of volatile substances i.e. gas, glue, lighter fluid etc.
wants to cut down or stop using alcohol or drugs but is finding it difficult to do so.
is under 13 and reports any drug misuse
is experiencing ‘problematic drug use’. I.e. use which results in social, financial, psychological, physical or legal problems as a result of their drug use
is misusing substances and has mental health issues
is offending in order to fund substance misuse

Section C

Main substance/issue and Key risk factors

e.g. Accommodation/Support/Health problems/Mental Health/Pregnant/Social services/Violence/Crime/Education/Employment/Training/other

Completing this form:

• Please print this page prior to submission
• Referrals made by email (including using this form), paper copies MUST follow, secure fax 01325 346 814 or posting (address below).
• Referrals will be acknowledged upon receipt and allocated within one working day if thought acute, 5 working days for all other cases
• Please contact the SWITCH team if you are unsure about any aspect of this referral.

Contact Details: For referral or advice/assessment

If aged 10-18 with significant substance misuse problems	SWITCH – Young People Substance Misuse Team Tel: 01325 346283 Fax: 01325 346814
Under 16 and concerns of a moderate to severe mental health problems	CAMHS Tel: 01325 380100 Fax: 01325 743732
Under 18 and general concerns of risk/vulnerability	Children’s Childcare Duty Team Tel: 01325 346200/346867 Fax: 01325 346479

Switch

Young Peoples Substance Misuse Team
Central House Annex,
Gladstone Street,
Darlington
DL3 6JX