M32 Referral Form

Details of Young Person

Referrals can only be made for young people who are currently living with, or have regular overnight contact with their substance using parent(s). Young people need to be aware of their parent’s substance use. For information on support for children who are living with a non drug-using carer, but have been affected by a parent’s use or are experimenting with substances themselves, please call the Bristol Youth team on 0117 987 6008.

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Gender

Language Spoken at Home

Ethnicity

Ok to contact Young Person by:(Required)

Phone

Mobile

Text

Letter

Other

Ok to contact Parents by:(Required)

Phone

Mobile

Text

Letter

Other

Parent's details

Name(s)(Required)

Date of Birth(Required)

Phone number

Address (if different to Young Persons)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Person making Referral

Name(Required)

First Last

Organisation(Required)

Position

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referral details

Brief details of Young Person’s Situation, including impact of parental drug or alcohol-use on the young person.

(Please note that because we are an adult drugs service children MUST be aware of their parent’s drug-use. Parents should be informed that we shall mention BDP in the assessment.)

Is the young person aware of their parent’s drug-use?(Required)

Yes

(if no, then please phone the Family Team before continuing with this referral)

Does the child live permanently with the parent(s)?(Required)

Yes

Details of home situation – in particular parental substance use and any support accessed by parent(s)

Does the child have a Social Worker?

Yes

If yes, name and locality:

Which other agencies are involved with the family?

Please provide as much detail as you are able (e.g. name and contact phone numbers)

Is the parent receiving treatment/willing to engage in treatment – please give details

What will your ongoing role be with this family?

Are there any potential risk-factors involved in visiting this family? (e.g. aggression/violence of family members)

Please add any comments about this referral, including areas of concern where you hope we can support the young person

M32 Referral Form

M32 Referral Form

Details of Young Person

Parent's details

Person making Referral

Referral details

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