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SELF REFERRAL FORM
ABOUT YOU
First name(s) (Required)
Surname (Required)
Date of birth (Required)
Email address
Telephone (Required)
Address (Required) Please mark NFA if you are of no fixed address (Required)
Postcode
EmailLetterTelephoneText
YesNo If no, please give details:
YesNo
Gender (Required) —Please choose an option—MaleFemaleOtherPrefer not to say
Ethnicity (Required) —Please choose an option—White BritishWhite IrishWhite OtherWhite & AsianWhite & Black CaribbeanWhite & Black AfricanMixed OtherAfricanCaribbeanBlack OtherBangladeshiIndianPakistaniAsian OtherChineseOther
HEALTH INFORMATION
Drug use supportAlcohol use supportFamily supportOther Please give details of the support needed below:
Heroin/opiatesCocaineCrack cocaineCannabisCrystal meth/methamphetamineAmphetamine/speedAlcoholSolventsNew psychoactive substancesPrescribed medications (e.g. Benzodiazepine, Gapapentin)Other
Please give details including how much and how often the substance is being used:
If you have completed an alcohol or drug audit, what is your score?
Your GP (Required) Please write 'Not registered' if you do not have a GP (Required)
GP's address
GP's postcode
Do you have access support needs e.g. mobility or interpreter requirements? If yes, please give details:
Do you have any neurodiversity access support needs? If yes, please give details:
Is there anything else you would like to tell us?
How did you hear about us?
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Date of submission
Submit this form and we will contact you to arrange an appointment.
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