This field is for validation purposes and should be left unchanged.

Introduction

This referral form is intended for professionals referring individuals into the APS Early Intervention Craving Pathway™. The pathway supports adults experiencing stress-related coping behaviours involving alcohol, cannabis, smoking, chocolate, or other non-dependent substance or behavioural cravings. Referrals should only be made where informed consent has been obtained from the individual and a brief telephone consultation with the referrer has taken place to confirm suitability.

Referrer Details

Referrer Name(Required)

Client Identifier

Please do not include full name

Primary reason for referral

Options(Required)
Brief summary of emotional triggers, coping behaviours, and current difficulties.

Suitability Screening

Current pattern appears to be:(Required)
Client appears suitable for outpatient therapeutic support
Please tick all that apply
Is there evidence of any of the following?(Required)

Safeguarding

Are there current safeguarding concerns?(Required)

Consent and Information sharing

Client consent Confirmation(Required)
I confirm that the client has given informed consent for this referral and understands that their information will be shared with A Positive Start CIC for the purpose o accessing the APS Early Intervention Craving Pathway™
Consent to share progress update with referrer(Required)

Contact Preferences

Preferred contact route for client(Required)

Additional Information

Please include only information relevant to referral suitability and support planning.

Submission Statement

Declaration(Required)
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