DAFS Client Information Form

DAFS Client Information Form
Referrer Details (if not a self referral)
Referrer Name
Referrer Email
Referrer Phone Number
Referring Agency
Client Details
Full Name

First NameLast Name
Date of Birth
Address

Street Address

Street Address Line 2

Town/CityCounty

Postcode
Telephone
Email
example@example.com
How did you hear about DAFS?

Social MediaWord of mouthSaw them at a community eventReferral from another agencyOnline search for helpOther
Gender

MaleFemaleOtherPrefer not to say
What is the relationship with your loved one with the substance misuse disorder?

I am their parent?I am their partner?I am their adult child (over 18)?I am their sibling?I am their friend?Another relationship?
What type of substance is involved?

DrugsAlcoholBoth
Your ethnicity
Are you an Armed Forces Veteran?

YesNo
Any relevant risk information we should be aware of?

Risk to selfRisk from othersDomestic abuseMental ill healthChild protectionNone
To ensure the safety of our volunteers, please give further information in relation to any of the risks identified above
Are there any other agencies involved with the family?

Children's servicesSocial servicesDrug and alcohol servicesMental healthProbationOther*
*Other
Signature

Clear
How we will use the information about you?

We collect this information in order to contact you and to understand your situation so we can best support you. We also record information such as ethnicity, age, gender, relationship and type of substance for analytical purposes.

This information will be stored safely or our database and will not be shared outside of DAFS.

If you no longer wish us to hold this information or you leave DAFS support group, we will delete all data held. You can also request this by emailing us as dafsmk@mail.com
Should be Empty:

DAFS Client Information Form

Referrer Details (if not a self referral)

Client Details