Henvisning ROP-team (Rus – psykisk oppfølgingsteam)
Sendes ROP-team, Postboks 4063, 2306 Hamar
(Sensitiv informasjon skal ikke sendes digitalt. Samtykke til henvisning må være gitt.)
Navn:_____________________________________________________________
Adresse:___________________________________________________________
Telefon:_____________________Født:___________________________________
Hvem henviser:__________________________Telefon:______________________
Bakgrunn for henvisning:_______________________________________________
___________________________________________________________________
Kort om rushistorie:___________________________________________________
___________________________________________________________________
Hovedrusmiddel:______________________________________________________
Tidligere utredning eller behandling:
___________________________________________________________________
___________________________________________________________________
Psykisk helse:
___________________________________________________________________
___________________________________________________________________
Eventuell diagnose av betydning:
___________________________________________________________________
___________________________________________________________________
Sosiale forhold:
___________________________________________________________________
___________________________________________________________________
Annet du mener bør med: (Bruk baksida etter at du har skrevet ut arket, hvis dårlig plass)
___________________________________________________________________
___________________________________________________________________