Views External

Client Details

Forename

Surname

DateOfBirth

Gender

Pronouns

Ethnicity

Address 1

Address 2

Address 3

Town

County

Postcode

Home Phone

Mobile

Preferred Contact Methods

Can we leave messages/voicemails?

Receive Appointment Reminders by Text?

Referrer Details

Name

Organisation

Job title

Department

Locality

Phone Number

Address

Postcode

Physical Health

Do you have any of the following impairments?

How long has drinking been a problem?

How often is alcohol consumed?

Units per week consumed

Units consumed on heaviest drinking day last week

Main Drug Category

Main Drug Type

How often is main drugs used?

Any other drugs used?

Main Drug Quantity

Criminal Justice

Is there a condition to attend or instruction by worker to attend?

Is the client MAPPA? If yes, what management & risk level are they? Who is at risk?

Are there any risks we need to be aware of?

Please list any offences & license conditions

Length of Order & License Expiry Date

Date Imposed

Are reports required?

Engagements With Other Services

Is Client Engaged With Any Other Services? (e.g. CAT Team, Psychological Services)

North Lanarkshire Counselling Referral

Client Details

Referrer Details

Physical Health

Presenting Issues

Criminal Justice

Engagements With Other Services