Referral Form for Patients with Alcohol Problems
First name
Address
Surname
DOB
Telephone
numbers
Post Code
Referral date
Referrer’s
name,
status,
address and
phone
number
GP name,
address and
phone
number
Current problem
Full AUDIT score
Alcohol problems
/40
Alcohol dependent
Binge drinker
Other alcohol problem (give details below)
Details of problem: quantity of alcohol consumed, duration of problem etc
Complications (give details below)
h/o seizures or hallucinations in withdrawal
Significant relevant physical health problems
h/o violent, threatening or abusive behaviour
h/o self harm
Other mental health issues
Related forensic/criminal history
Details
Previous treatment (service used, when, treatment received, outcomes)
What does client want? What is their motivation for change?
Other information
PTO for advice about choice of service
Community Alcohol Services in West Essex
Use this referral form for ADAS and CDAT services.
PLEASE TICK THE BOX OF THE SERVICE WHICH IS REQUIRED
Send direct to the relevant service. You can also phone to refer/discuss referrals.
ADAS (Extended Brief Interventions and Brief Treatment/Community Alcohol Service)
 A service for moderate non-dependent drinkers with AUDIT scores between 8-19 (8-15
hazardous/increasing risk and 16-19 harmful/higher risk) who are motivated to change
 Help to reduce and/or control alcohol consumption
 Detailed self monitoring of alcohol consumption
 Up to 6, 20–30 minute sessions in easily accessible locations agreed with the patient
 Healthier lifestyle advice and alternatives to drinking
ADAS, 118-124 The Stow, Harlow, Essex, CM20 3AS
Email: admin@adasuk.org
Tel 01279 438716 / 641347, Fax 01279 641140
ADAS (Alcohol Misuse Service/Central Office)
 Assessment and support for clients who consider themselves to have a problem with alcohol
 Identification of alcohol misuse using approved screening tools
 Provision of information on sensible drinking
 Simple brief interventions to reduce alcohol related harm
 Triage and holistic assessment
 Open access facilities and outreach that provide alcohol specific advice, information and support
 Brief interventions, motivational interviewing or motivational enhancement therapy eg FRAME
 Assessment of the needs and safety of children and vulnerable others living with problem alcohol
users and the provision of access to the appropriate intervention or support
 Pre-treatment and support as requested by CDAT (Community Alcohol & Drugs Team) for those
entering detoxification programmes
 Access to basic health screening and signposting to other services such as virus
screening/vaccination for Hep B/Hep C/HIV/Aids if appropriate
 Referral for more appropriate interventions for those who are alcohol dependent and/or suffering
harm
 Supported ‘step-down’ from Tier 3 for those who have undergone community or residential
detoxification or detoxification and rehabilitation
 Automatic ‘opt-back’ and relapse prevention
ADAS, 118-124 The Stow, Harlow, Essex, CM20 3AS
Email: admin@adasuk.org
Tel 01279 438716 / 641347, Fax 01279 641140
Community Drug and Alcohol Team (CDAT) West Essex
 Assessment for patients physically dependent on alcohol who require detoxification
 Patients accepted for detoxification may be able to attend weekly preparatory group
 Detoxification is either as an inpatient at Greig House in London or in the community at the client’s
home (for low risk clients)
 After care is provided via other partners including ADAS and Alcoholics Anonymous
 Weekly drop in group
 Joint work with mental health in dual diagnosis
 ATR (alcohol treatment requirement) from probation. Joint work with probation
 Apply for rehabilitation placement
CDAT, Aylmer House, Kitson Way, The High, Harlow, CM20 1DL
Tel 01279 698721, Fax 01279 698722
Other organisations work with people with alcohol problems in this area:
 Alcoholics Anonymous. Patients can self refer – national helpline: 0845 769 7555
 EYPDAS (Essex Young People’s Drug & Alcohol Service) for the under 18’s - referrals and selfreferrals accepted on 01245 493311
Clients can be referred for residential rehabilitation by CDAT