Recovery Registration Form
v1d (m) – these items are mandatory and MUST BE COMPLETED
Referral & Assessment details
(m) Referral Source
(m) Date Referral
Received
(m) Presented/Registration
Date
(m) Assessing Worker:
Accessibility to Services
Will communication or accessibility support be required for you to receive an assessment:
(Language/translator, reading or writing support, disability)
Yes
No
Specify:
Service User details
(m) First name:
(m) Surname:
(m) DOB:
(m) Age:
(m) Gender:
(m) Nationality:
(m) Ethnicity:
Male
Female
First language:
Address:
(m) Postcode:
Contact Numbers:
(m) Local Authority:
How is it best to contact you?
E-mail:
(m) DAAT:
Phone
Letter
Can we write to you at the address you have given? Yes
Text message
NHS number:
e-mail
No
Can we leave messages on the telephone numbers you have given? Yes
GP details
Name:
Address and contact number:
You see your GP at the GP surgery:
No
Next of Kin
(m) GP Name & Surgery:
Knows about alcohol and/or drug use :
Other – state ……………………...
Relationship to you:
Yes
Yes
No
No
Address and contact number:
Knows about alcohol and/or drug use:
No
Yes
Not registered with a G.P.
Current medication/treatment:
(We will only contact this person in the case of an emergency)
Page 1 of 6
Recovery Registration Form
v1d (m) – these items are mandatory and MUST BE COMPLETED
Previous treatment
(m) Have you previously received treatment with Structured Treatment Alcohol / Drug services:
Yes
No
Current contact with other services
(m) Are you currently receiving any support from Mental Health Services:
Yes
No
(Dual Diagnosis indicator)
Are there any other services you are currently in contact with or receiving a service from:
Yes
No
If yes, who are they?
Housing and Employment
(m) Accommodation Need:
No fixed abode
Housing with problem
No housing problem
Details:
(m) Accommodation Status: (please select one)
Approved premises
Council
Housing association
Owned property
Rented
Settled with family/friends
Supported Housing
Traveller
Hospital - general
Hospital - psychiatric
Hostel
Living in care
Rough sleeper
Sofa Surfing
Temporary - other
Prison
NFA
Other inappropriate housing
(please specify
(m) Employment:
Regular employment
Unemployed and seeking work
Retired from paid work
Pupil/Student
Unemployed - not receiving benefit
Homemaker
Long term sickness or disabled
Unemployed – unpaid voluntary work
Other
Not stated (decline to answer)
Relationships
(m) Significant Other Status:
Single
With a partner
Married
In civil partnership
Divorced
Widowed
Separated
(m) Sexual Orientation
How would you describe your sexual orientation?
Heterosexual
Homosexual
Bi-sexual
Other
Prefer not to state
Page 2 of 6
Recovery Registration Form
v1d (m) – these items are mandatory and MUST BE COMPLETED
Children (aged 18 or under)
(m) Currently pregnant:
Yes
Parent to children under 18:
No
Yes
How many?
No
(yourself only, do not tick if your partner is pregnant)
(m) Parental status – your own children under 18
Not a parent
None of the children live with the client
All the children live with you
Declined to answer
Some of the children live with you
(m) ALL CHILDREN - children you are parent to or have access to at least 1 night a week?
Where are these children and how many in each location – PLEASE INDICATE IN NUMBERS
Client:
Partner or ex:
Grand-parent:
Other Family:
In Care:
Elsewhere:
Who is the primary care giver for these children?
(m) ALL CHILDREN - children you are parent to or have access to at least 1 night a week?
Child Looked After / Foster Care
Neither
Subject to Child Protection Plan
Declined to answer
Both
Childs’ Name
Date of Birth
School
Alcohol Use - complete even if not main substance issue
(m) Age first used:
(m) Number of days you
have consumed alcohol in
the last 28 days?
(m) Average alcohol
consumption IN UNITS in the
last 28 days:
Per day
(m) Number of days in the
last 28 days you have
exceeded the binge limit?
Per week
Alcohol type, Quality,
Quantity and Strength
(Binge limit: Men: 8 units per day,
Female: 6 units )
When was the last time you had a drink of alcohol? ……………………………
Alcohol type: ……………………………………..
How much (quantity): ………………………………………...
Drinking Pattern:
Morning
Lunch Time
Afternoon
Alone
With family/friends
In bouts
Monthly
Weekly
Evenings
All day
All night
Variable
At Home
At pub
On street
Variable
Days per week
Page 3 of 6
Recovery Registration Form
v1d (m) – these items are mandatory and MUST BE COMPLETED
Have you experienced any of the following symptoms in relation to your alcohol consumption, over the past 6
months:
Morning drinking
Morning nausea/vomiting
Shakes
Sweats
Depression
Delirium tremens
Blackouts
Memory Loss
Hallucinations
Peripheral Neuropathy
Insomnia
Loss of appetite
Anxiety/Panic attacks
Convulsions
Audit – Alcohol Use Identification Test
1. How often do you have a drink containing alcohol?
(0) Never [skip to Qs 9-10]
(1) Monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 or more times a week
(m) score _________
2. How many drinks containing alcohol do you have on a
typical day when you are drinking?
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7, 8, or 9
(4) 10 or more
(m) score _________
3. How often do you have six or more drinks on one occasion?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
(m) score _________
Skip to Question 9 and 10 if total score for Question 2 and 3 =
0
4. How often during the last year have you found that you were
not able to stop drinking once you had started?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
(m) score _________
5. How often during the last year have you
failed to do what was normally expected
from you because of drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(m) score _________
(m) AUDIT score :
0-40
Drinking level:
6. How often during the last year have you needed a
first drink in the morning to get yourself going after a
heavy drinking session?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
(m) score _________
7. How often during the last year have you had
a feeling of guilt or remorse after drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
(m) score _________
8. How often during the last year have you been
unable to remember what happened the night before
because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
(m) score ________
9. Have you or someone else been injured as a result
of your drinking?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
(m) score _______
10. Has a relative, friend or a doctor or another health
worker been concerned about your drinking or
suggested you cut down?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year (m) score ________
Safe (0-7)
Hazardous (8-15)
Harmful (16-19)
Dependant (20-40)
Page 4 of 6
Recovery Registration Form
v1d (m) – these items are mandatory and MUST BE COMPLETED
Substance Use – what do you need help with (include alcohol if appropriate)
Detail your general patterns of use – even if you are not currently using them – e.g. if you are being
prescribed a replacement medication – tell us about what it is replacing rather than the medication itself. .
(m) Main substance:
(m) Source
prescribed GP
other prescribed
prescribed SMS
prescribed & illicit
purchased legally
street illicit
(m) Route of Use:
Inject
Sniff
Smoke
Oral
(m) Second substance:
(m) Age first
used:
Other
prescribed GP
other prescribed
prescribed SMS
prescribed & illicit
purchased legally
street illicit
(m) Route of Use:
Sniff
Smoke
Oral
(m) Third substance:
(m) Age first
used:
Other
(m) Weekly
spend:
prescribed GP
other prescribed
prescribed SMS
prescribed & illicit
purchased legally
street illicit
(m) Route of Use:
Sniff
(m)
Frequency:
(m) Source
(please mark N/A or strike through if No Third
substance issue)
Inject
(m) Weekly
spend:
(m) Source
(please mark N/A or strike through if No
Second substance issue)
Inject
(m)
Frequency:
Smoke
Oral
(m) Age first
used:
Other
(m)
Frequency:
(m) Weekly
spend:
Injecting information
(m) Injecting Status:
Never
Current
(m) First Injected Age:
(m) Injected in the last 28
days:
Previous
Yes
(m) Ever shared injecting equipment:
Yes
No
No
(m) Have you shared injecting equipment in the last 28 days:
Yes
No
(m) Total number of days
Health Care - sexual health
(m) Sex Worker
No
Mostly from Premises
Mostly on the street
Page 5 of 6
Recovery Registration Form
v1d (m) – these items are mandatory and MUST BE COMPLETED
Health Care - Blood borne viruses
(m) Have you ever been referred to Hepatology (liver
unit):
Yes
No
(m) Previously Hep B Infected
Yes
No
(m) Hep B treatment status:
Offered & accepted
Offered and refused
** Assessed as not appropriate
Immunised already
Have acquired immunity
**Not offered
** Please give details:
(m) Current Hep B vaccination course count (Only complete if “Offered and Accepted”)
1
2
3
Booster
(m) Ever Hep C
Tested:
Yes
None
(m) Hep C last test date
(m) HIV tested
(can give an approximate date):
Yes
No
Date ____________
No
(m) Positive:
(m) HIV Positive
Yes
No
Unknown
Yes
No
Unknown
(m) Hep C Test Intervention status:
Offered & accepted
Offered and refused
** Assessed as not appropriate
** Not offered
** Please give details:
(m) Have you ever had a tetanus Vaccination?
Yes
No Date ________________
Service User consent for re-engagement
May we contact you if you disengage with services in order to establish if you would like to regain contact
and receive support to re-engage you?
Yes
No
How may we contact you?
Telephone call
Mobile call
Text
Family member
Other treatment provider
Email
Letter
Next of kin
Service User / Peer mentor
Home visit/outreach
Other
Give details of preferred contact method(s)
Service User name:
Service Signature:
Assessors name:
Assessors Signature:
Date:
Page 6 of 6