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Referral made by*
Agency*
Contact Details*
Referral Date*
Name*
Date of Birth*
Telephone Number*
Address*
Postcode*
Brief summary including risk details/Substance use.*
Other Professionals involved:
Disclosure/Consent
If there is a concern about your safety or the safety of others, we may need to share information without your consent. However, we will strive to inform you if this needs to happen beforehand. Please indicate where you give consent for us to share information with the following agencies:
Seaview Wellbeing Centre, RADAR, SASS, Harm Reduction
Consent to share info?* —Please choose an option—YesNo
Date consent given
Any limitations on consent? and details:
STAR Alcohol and Drug Treatment Service
Adult Social Care (ESCC)
Brighton Oasis Project/Empower
Care Navigator's Service/Prison In Reach (ESVH)
Sussex Police
Luna Project
Adfam Carers Service
Probation
St Johns Ambulance
MH Team (Sussex Partnership Trust)
CA 1066
Rough Sleepers Initiative (RSI)
IC 24 Station Plaza walk in service
All Appropriate Contacts
Department of Work and Pension
GP Practice
Housing Services
Other:
Consent to share info? —Please choose an option—YesNo
Please type your name as signature below
Client Signature*
Date:
Worker Signature*
By submitting the form above you consent to be contacted by Seaview Project using the details provided.
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