If there is an emergency call 999 or if you are experiencing a crisis call 0845 608 0525
NHS

Referral Form

Bexley Drug and Alcohol Team, 50 Pier Road, Erith Kent DA8 1RQ
Telephone: 01322 357940 / Fax: 01322 357960 / Email: slm-tr.PierRoadProject@nhs.net

  • Contact Details

    (for the referrer and the client / patient being referred)
  • (service / agency, address, phone number, fax number)
  • MM slash DD slash YYYY
  • Substance used (inc. alcohol)Amount used (in £’s / grams / alcohol units & alcohol %)Method of use (injected /smoked / snort / oral)Frequency of use (daily / twice weekly / etc) 
  • Risk Assessment

    Does the client have any issues with the following? (please circle & provide full details, thank you)
  • (mobility / history of DVT / recent hospital admission / Hep B C HIV / breathing problems / fits or seizures, alcohol related?)
  • (depression / anxiety / psychosis / suicidal ideation / history of suicide attempts / self harm / any prescribed medication?)
  • (housing issues / Social Services involvement or child at risk / self neglect/ social isolation / criminal activity / violence / arson?)
  • (injecting substances (previous/ current)/ AUDIT score (& please attach)/ recent abstinence/ alcohol dependent?)