1. No category

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:_______________________________________________
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Kort om rushistorie:___________________________________________________
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Hovedrusmiddel:______________________________________________________
Tidligere utredning eller behandling:
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Psykisk helse:
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Eventuell diagnose av betydning:
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Sosiale forhold:
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Annet du mener bør med: (Bruk baksida etter at du har skrevet ut arket, hvis dårlig plass)
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