Oasis Women's Recovery Service Referral Form
Page 1
Are you referring yourself?
Please select...
Yes
No
Page 2
Referring service details
Name of service
Service type
Please select...
Advice agency
Community mental health services
Community substance misuse services
Day centre
Domestic violence service
Drug / alcohol service
Faith organisation
Floating support
GP / Hospital / Health authority
Hostel
Job Centre Plus
Local authority - adult social services
Local authority - children's service
Local authority - housing / homelessness department
Local authority - other
Local authority - probation services
Night shelter
Outreach / No Second Night Out (NSNO) team
Police / safer streets team
Prison
Rolling shelter
Sexual health service
Sexual violence services
Social services
Other
Your full name
Phone
Email
Contact details
First name
Last name
Date of birth
(DD/MM/YYYY)
Phone
Email:
Address 1
Address 2
Town / City
County
Country
Please select...
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Postcode
Date moved in at this address
(DD/MM/YYYY)
If the exact date is unknown, please give your best estimate.
Your family
Do you have children under 18?
Please select...
Yes
No
Prefer not to say
Are they living with you?
Please select...
Yes
No
Prefer not to say
Please provide details of who/ages:
Are you or your partner pregnant?
Please select...
Yes
No
Prefer not to say
If yes, please provide details:
Name of your Next of Kin
Their phone number:
Next of Kin's address
Client's family
Does the client have children under 18?
Please select...
Yes
No
Did not ask
Client did not wish to disclose
Are the children residing with the client?
Please select...
Yes
No
Did not ask
Client did not wish to disclose
Please provide details of who/ages:
Is the client or client's partner pregnant?
Please select...
Yes
No
Client did not wish to disclose
If yes, please provide details:
Name of client's Next of Kin
Relationship to the client
Please select...
Aunt
Brother
Carer
Cousin
Daughter
Ex-partner
Father
Father-in-law
Foster father
Foster mother
Friend
Grandfather
Grandmother
Husband
Mother
Mother-in-law
Neighbour
Nephew
Niece
Partner
Sister
Son
Stepfather
Stepmother
Uncle
Wife
Other
Next of Kin's phone number
Next of Kin's address
Equality and diversity
Gender
Please select...
Male
Female
Non-binary
Other (please specify)
Prefer not to say
Other gender:
Does the client have a disability or health condition?
Please select...
Yes
No
Prefer not to say
What is the impact of the disability or health condition on their life?
Sexual orientation
Please select...
Bisexual
Gay
Heterosexual
Lesbian
Other (please specify)
Prefer not to say
Other sexual orientation:
Ethnic origin
Please select...
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Other (please specify)
Asian/Asian British: Pakistani
Asian/Asian British: Prefer not to say
Black/Black British: African
Black/Black British: Caribbean
Black/Black British: Other (please specify)
Black/Black British: Prefer not to say
Mixed: Other (please specify)
Mixed: Prefer not to say
Mixed: White & Asian
Mixed: White & Black African
Mixed: White & Black Caribbean
White: British
White: English
White: Gypsy or Irish Traveller
White: Irish
White: Northern Irish
White: Other (please specify)
White: Prefer not to say
White: Scottish
White: Welsh
Other ethnic group: Arab
Other ethnic group: Prefer not to say
Other (please specify)
Prefer not to say
Did not ask
Other ethnic origin:
Page 3
Please tell us as much as you can about your substance use.
Main substance details
Primary substance
Please select...
Alcohol
Benzo/Sleepers
Cannabis
Cocaine
Crack
Crystal
Crystal Meth
Ecstasy
GHB/Liquid Ecstasy
Heroin
Ketamine
Khat/Chat
Legal Highs
Magic Mushrooms
MDMA
Mkat
Nos/Glue/Sprays/Poppers
Prescription drugs
Ritalin/Speed
Sleeping tablets/Laxatives
Steroids
New drug
Other
If selected 'Other', please specify the substance here:
Substance cost per typical day
Please select...
Up to £10
Up to £20
Up to £30
Up to £50
Up to £100
Up to £200
Alcohol units per typical day
Please select...
0-5 units (up to 2 glasses of wine)
5-10 units (up to 4 glasses of wine)
10-15 units (up to 6 glasses of wine)
15-20 units (up to 8 glasses of wine)
20-30 units (up to 13 glasses of wine)
More than 30 units
Frequency of consumption
Please select...
Daily
A few times a week
Once a week
A few times a month
Once a month
Less than once a month
Second substance details
Second substance
Please select...
Alcohol
Benzo/Sleepers
Cannabis
Cocaine
Crack
Crystal
Crystal Meth
Ecstasy
GHB/Liquid Ecstasy
Heroin
Ketamine
Khat/Chat
Legal Highs
Magic Mushrooms
MDMA
Mkat
Nos/Glue/Sprays/Poppers
Prescription drugs
Ritalin/Speed
Sleeping tablets/Laxatives
Steroids
New drug
Other
If selected 'Other', please specify the substance here:
Substance cost per typical day
Please select...
Up to £10
Up to £20
Up to £30
Up to £50
Up to £100
Up to £200
Alcohol units per typical day
Please select...
0-5 units (up to 2 glasses of wine)
5-10 units (up to 4 glasses of wine)
10-15 units (up to 6 glasses of wine)
15-20 units (up to 8 glasses of wine)
20-30 units (up to 13 glasses of wine)
More than 30 units
Frequency of consumption
Please select...
Daily
A few times a week
Once a week
A few times a month
Once a month
Less than once a month
Third substance details
Third substance
Please select...
Alcohol
Benzo/Sleepers
Cannabis
Cocaine
Crack
Crystal
Crystal Meth
Ecstasy
GHB/Liquid Ecstasy
Heroin
Ketamine
Khat/Chat
Legal Highs
Magic Mushrooms
MDMA
Mkat
Nos/Glue/Sprays/Poppers
Prescription drugs
Ritalin/Speed
Sleeping tablets/Laxatives
Steroids
New drug
Other
If selected 'Other', please specify the substance here:
Substance cost per typical day
Please select...
Up to £10
Up to £20
Up to £30
Up to £50
Up to £100
Up to £200
Alcohol units per typical day
Please select...
0-5 units (up to 2 glasses of wine)
5-10 units (up to 4 glasses of wine)
10-15 units (up to 6 glasses of wine)
15-20 units (up to 8 glasses of wine)
20-30 units (up to 13 glasses of wine)
More than 30 units
Frequency of consumption
Please select...
Daily
A few times a week
Once a week
A few times a month
Once a month
Less than once a month
Page 4
Would the client like support from our Sex Workers Outreach Service in East Sussex?
Please select...
Yes
No
Is the client at risk of blood-borne viruses?
Please select...
Yes
No
Client did not wish to disclose
Based on current or previous substance use of snorting/injecting/sharing.
Is the client up to date with their sexual health screening?
Please select...
Yes
No
Client did not wish to disclose
Has the client been a victim of violence, abuse or control in the last year?
Please select...
Yes
No
Client did not wish to disclose
Who was the violence, abuse or control from?
Please select...
Partner in the home
Partner out of the home
Ex-partner
Family member in the home
Family member outside of the home
Other
Has the client been a victim of exploitation, sexual or otherwise, in the last year?
Please select...
Yes
No
Client did not wish to disclose
Who was the exploitation from?
Please select...
Partner in the home
Partner out of the home
Ex-partner
Family member in the home
Family member outside of the home
Other
Is the client receiving or seeking support around violence, abuse, control or exploitation?
Are there any other worries, risks or concerns, current or historic, for this client?
Does the client have any barriers to accessing our service/groups (e.g. social anxiety)?
Have you obtained client's consent, either verbal or written, to sharing of this information?
Yes
We have a Sex Workers Outreach Service in East Sussex, would you like support from this service?
Please select...
Yes
No
*If you would like details to call them yourself or for a friend, you can find more info on our website: www.oasisproject.org.uk, or call directly for a confidential talk on: 01273 675 526.
Are you at risk of blood-borne viruses?
Please select...
Yes
No
Prefer not to say
Based on current or previous substance use of snorting/injecting/sharing.
Are you currently up to date with your sexual health screening?
Please select...
Yes
No
Prefer not to say
*If you're unsure about either health questions, you can access free screening via your local sexual health/gum (apt or walk in) clinics for East Sussex.
Have you experienced violence, abuse or control from another person in the last year?
Please select...
Yes
No
Prefer not to say
Who was it from?
Please select...
Partner in the home
Partner out of the home
Ex-partner
Family member in the home
Family member outside of the home
Other
Have you experienced exploitation, sexual or otherwise, from another person in the last year?
Please select...
Yes
No
Prefer not to say
Who was it from?
Please select...
Partner in the home
Partner out of the home
Ex-partner
Family member in the home
Family member outside of the home
Other
Are you receiving or seeking support around violence, abuse, control or exploitation?
Do you have any other worries, risks or concerns, current or historic?
Do you have any barriers to accessing our service/groups (e.g. social anxiety)?
Do you consent to sharing of the information you've provided above?
Yes
Consents
Can we contact you by phone?
Yes
No
Can we contact you by email?
Yes
No
Please give us details of any other support needs:
Contact Information