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Referral Form

Referral / Self Registration into Specialist Services

Are you making this referral on behalf of someone else?
Client has given consent *

Client Details

I consent to referral to Horizon drug and alcohol service *

GP Details

Additional Information

Pregnant
Domestic ViolenceHave you had any involvement in domestic violence now or in the past?
Mental Health Conditions / Symptoms
Risk of self-harm or suicidal thoughts
Alcohol more than 40 units dailyfor example drinking 13 pints of strong lager, 3 bottles of red wine or a bottle of spirits
Hallucinationsthese can be visual (seeing things) or auditory (hearing things)
Injecting drug use
Physical health conditions/symptoms
Seizures
Learning Disabilities
Aggression
Probation
Adult Safeguarding, are you currently working with Adult Social Care?
Child Safeguarding, are there any children under the age of 18 in the household?
Are you open to Children’s Services?
Have you ever served in the armed forces?
Consent to outreach *A referral to the outreach team would be made if we were concerned about your welfare for example, we had not had any contact with you for a while. The outreach team are part of Horizon and come out to your home to do a check in.

Get In Touch

Talk to one of our friendly and professional experts today.

Call 01253 205157 email us on horizonreferrals@delphimedical.co.uk, or use our referral form.

All enquires are handled with total confidentiality.

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