GET HELP

If you need our help, please use the contact form below and a support worker will be in touch as soon as possible.

Please note: This form is for those who need our help only. If you have a general enquiry, please click here.

YOUR CONTACT DETAILS

Applicant Name

First Name

Last Name

Date Of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

National Insurance Number

FAMILY AND LIVING CIRCUMSTANCES

Marital Status

Number of Dependants

Age(s) of Dependant(s)

If applicable

Name of Treatment Centre

If Applicable

Referral Agency/Self

Employment Status

ACCOMMODATION

Have you ever lived in a supported housing environment?

Have you ever breached a tenancy agreement?

Have you ever committed acts of violence against staff or other residents in a place where you were living?

If yes, please provide details

Where have you lived in the past 2 years?

Who has provided support for you in the last 2 years?

(Professionals, voluntary groups, substance misuse, family etc)

PHYSICAL HEALTH

Height

Weight

How would you describe your health?

Do you have any physical Impairment, chronic disease or disability?

If yes, please provide details

Do you require assistance with daily living because of an impairment?

If yes, please provide details

Name and address of G.P. (or last seen doctor)

Do you take any prescribed medication?

If yes, please provide details, frequency, and dosage

SUBSTANCE MISUSE

When was the last time you took any illicit drugs or medication not prescribed by a doctor?

Please provide dates where possible and details of the drugs taken.

When was the last time you consumed alcohol?

YYYY

When was the last time you consumed legal highs?

(Including N.P.S.)

YYYY

What is/was your primary substance?

Have you recently left or are about to leave a treatment centre?

If yes, please specify your treatment centre and leaving date.

Are you currently being supported by a substance misuse service?

If yes, please specify the service and your key worker.

MENTAL AND EMOTIONAL HEALTH

Have you ever experienced mental or emotional health problems? Do you have any mental health diagnoses?

If yes, please provide details

Have you ever seen a psychiatrist?

Have you ever been hospitalised as a result of mental or emotional health problems?

If yes, please provide details.

Have you ever had an eating disorder?

If yes, please provide details.

Have you ever attempted to end your life or been known to self-harm? What was your intent? For Example, self-punishment, release, cry for help or to end your life?

If yes, please specify the most recent episode(s).

PREVIOUS OFFENCES

Do you have a criminal record?

If yes, please provide details.

Have you ever served time in prison?

If yes, please provide the following details: date(s), offence(s), and sentence(s).

Do you have any outstanding warrants?

If yes, please provide details on the issuing Constabulary or Court (including the full address)

Do you have any outstanding court appearances?

If yes, please provide the following details: Date(s), Offence(s), and Court(s).

Have you ever been convicted of a violent offence?

If yes, please provide the following details: Offence(s), Date(s), and Sentence(s).

Have you ever been the victim or perpetrator of domestic violence?

If yes, please provide the following details: Offence(s), Date(s), and Sentence(s).

Have you ever been convicted of a sexual offence?

If yes, please provide the following details: Offence(s), Date(s), and Sentence(s).

Have you ever been convicted of arson?

If yes, please provide the following details: Offence(s), Date(s), and Sentence(s).

Are you currently under any order from a court or supervision?

(Prison licence, unpaid work, C.B.O, A.S.B.O etc) If yes, please provide details including name and telephone number of supervising officer.

Are you currently in custody?

If yes, what is your earliest date of release? (DD/MM/YYYY)

ADDITIONAL CONTACT (THEIR DETAILS)

Additional Contact

First Name

Last Name

Phone

(###)

###

####

PERSONAL STATEMENT

Please write in your own words why you want to come to The Silkworth Project and what recovery means to you.