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Guidelines for completing this form:

* Please type the details of your referral in the white color boxes provided below and e-mail
the completed form; the appropriate Tier 2 & 3 address details are at the end of this form.

  *  In the interest of working effectively with young people, it is expected that the client you are
      referring is aware of this referral and has indicated some level of interest in being referred
      to this drugs service.

  *  This referral form has been designed to ensure that it takes you no longer than 10mins
       to complete, but if you do have any difficulties completing this form, please do not hesitate in
      contacting the appropriate Tier service for assistance (numbers are at the end of this form).

  *  For further information about drugs services in Havering and/or to complete this referral
       form in, please visit our website (see address above) or contact the staff on the phone numbers
       at the end of this form.

Complete the online form or download the form and complete and send or fax to the Tier 2 Youth Awareness Project.

* indicates mandatory field

1. REFERRER'S DETAILS

* Referring agency / Internal Referral :	* Name :

Post :	Date of Referral :

Contact address :

Contact Information :


Postcode :

* Work :
Mobile :
* Email :

2. YOUNG PERSON'S DETAILS

* Young Person's Full Name:	Alias:

* Date of Birth:	Ethnicity:

Age:	Disability:

Contact address

Contact Information.

Work :
Mobile :
Email :

* Accommodation Type:

* Name of Parent/ Guardian:

Address:

Contact nos.

Home :
Mobile :
Email :

GP's Name :

Address:

3. RISK & PROTECTIVE FACTORS (Please refer to your screening tool to complete this)

* Reason for Referral (Please focus on risk factor, e.g. suspected substance use/misuse, offending behaviour, exclusion) :

Protective Factors (Please focus on positive aspects of the client's life, e.g. education, achievements, relationships)

Other Agencies Involved:

Please describe briefly the views of this young person regarding the referral:

Is the Parent/Carer aware of this referral:YesNo
What will be the most suitable way to arrange an induction meeting:

Thank you for your Referral.

For the Tier 2 Drugs Service (01708 433 342), please return to jenny Houlihan: jenny.houlihan@havering.gov.uk
For the Tier 3 Drugs Service (01708 433 342), Please return to Gail Bloomfield: gail.bloomfield@havering.gov.uk

Please expect either drug service to respond within 3 working days.

If you do not hear from this service within 3 days and in the interest of monitoring service performance, please contact Daren Mulley on 01708 434 280