Comprehensive, Responsive and Effective
Freedom Recovery Centre
Services For Addiction
14 Pattenden Road, Catford, London SE6 4NQ
1:
Home
1.1:
Mission Statement
1.2:
History
1.3:
Structure
1.4:
Staff Team
1.5:
Overview
2:
Services
2.1:
Day Programme
2.2:
Step Down
2.3:
Counselling
2.4:
Accommodation
2.5:
Timetable
2.6:
Gender Groups
2.7:
Voluntary Aftercare
2.8:
Family/Fun Day
3:
Forms
4:
Testimonials
5:
Site Map
6:
Contact Us
FRC REFERRAL FORM
Name:
Sex:
Male
Female
DOB:
Age:
Ethnic Group:
Current Address:
National Insurance No:
Country of nationality
at birth:
Sexuality:
Consent:
Yes
No
Homeless:
Yes
No
Registered Disabled:
Yes
No
In Receipt of Housing Benefit:
Yes
No
Funding Needed:
Yes
No
Benefit Type:
Amount £
If on benefit, office claimed at:
Previously Treated
Tier 3, 4:
Yes
No
Any Previous Treatment/Re-Hab/
Counselling:
Do you need a detox?:
Yes
No
Medication Prescribed/Non prescribed:
Drugs Legal/Illegal:
Physical Health. Previous/Present
Mental Health. Previous/Present
Suicide Attempts
Criminal History (Violence, Sexual Violence, Arson)
Current Court Cases/Probation/
Parole:
Contact with other Agencies:
Reason for seeking
help now:
DRUG USE PROFILE
Main drug:
Age of first use of main drug:
Route:
Inject
Oral
Sniff
Smoke
Other
Frequency of use:
When did you last use?
Second drug:
Third drug:
Injected status:
Current
Never
Previous
Injected in the last
30 days:
Yes
No
Shared equipment:
Yes
No
ALCOHOL USAGE
Drinking days:
Units of Alcohol:
Dual diagnosis:
Yes
No
PERSONAL STATUS
Parental status:
Children:
Pregnant:
Yes
No
Employment status:
Sex worker:
Yes
No
Accommodation Need:
Urgent
NFA
No housing problem
REFERRAL DETAILS
Referral source:
Referred by:
Address:
Postcode:
Borough of Residence:
Telephone No:
Referral Date:
Possible assessment Date:
Type of Modality:
Residential
Non-Residential
Aftercare
Counselling
