EMPOWER Referral Form

Page 1

Are you referring yourself?

Page 2

Referring service details

Name of service

Service type

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

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?

Are they living with you?

Please provide details of who/ages:

Are you or your partner pregnant?

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?

Are the children residing with the client?

Please provide details of who/ages:

Is the client or client's partner pregnant?

If yes, please provide details:

Name of client's Next of Kin

Relationship to the client

Next of Kin's phone number

Next of Kin's address

Equality and diversity

Gender

Other gender:

Does the client have a disability or health condition?

What is the impact of the disability or health condition on their life?

Sexual orientation

Other sexual orientation:

Ethnic origin

Other ethnic origin:

Page 3

Please tell us as much as you can about your substance use.

Main substance details - please note EMPOWER is for clients whose primary substance is crack or heroin

Primary substance

If selected 'Other', please specify the substance here:

Substance cost per typical day

Alcohol units per typical day

Frequency of consumption

Second substance details

Second substance

If selected 'Other', please specify the substance here:

Substance cost per typical day

Alcohol units per typical day

Frequency of consumption

Third substance details

Third substance

If selected 'Other', please specify the substance here:

Substance cost per typical day

Alcohol units per typical day

Frequency of consumption

Page 4

Would the client like support from our Sex Workers Outreach Service in East Sussex?

Is the client at risk of blood-borne viruses?

Based on current or previous substance use of snorting/injecting/sharing.

Is the client up to date with their sexual health screening?

Has the client been a victim of violence, abuse or control in the last year?

Who was the violence, abuse or control from?

Has the client been a victim of exploitation, sexual or otherwise, in the last year?

Who was the exploitation from?

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?

*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?

Based on current or previous substance use of snorting/injecting/sharing.

Are you currently up to date with your sexual health screening?

*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?

Who was it from?

Have you experienced exploitation, sexual or otherwise, from another person in the last year?

Who was it from?

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?

YesNo

Can we contact you by email?

YesNo

Please give us details of any other support needs: