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All information provided on this referral form will be kept secure and confidential on the AWESO data management system. Only with the express consent of the individual being referred, or in cases where there is a serious risk of harm or concerns about safeguarding, is information disclosed to third parties.
Your Details:
Safe to use?
Safe to use?
What kind of abuse are you currently experiencing?Tick all that apply
Are you residing in a jointly owned/rented property?
Are you currently employed?
Do you have a support network around you (family and/or friends) ?
Are you taking any prescribed medication?
Are you self-medicating with any other substance/s?
Are you self-harming?
Do you have any suicidal thoughts?
Client is aware/has been informed Aweso’s peer support group?
I agree the details in the form are true as of the submitted date Don’t agree
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