Alcohol & other drugs Self Referral Form

SELF REFERRAL FORM

What service location would you like to refer into? (Required)
—Please choose an option—Inspire, SuttonWokinghamWorcestershireSandwellWindsor & Maidenhead

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

How should we contact you? Select all that apply (Required)

PhoneTextEmailLetter Other. Please specify:

Can we contact you at any time?

YesNo If no, please give details:

Can we leave a voicemail?

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

What do you need help with? Select all that apply (Required)

Drug use supportAlcohol use supportFamily supportOther Please give details of the support needed below:

What substances do you use? Select all that apply (Required)

Heroin/opiatesCocaine/crackCannabisCrystal 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:

Are you pregnant?

YesNo
Are you currently injecting substances.

YesNo
Have you been admitted to hospital in the last month?

YesNo

Is there anything else you would like to tell us?

Personal information is important to us and we will keep it confidential. Occasions where we may need to share information are outlined in our privacy and confidentiality policy. You can read our privacy policy here, or alternatively you can ask for a copy from us.

Submit this form and we will contact you to arrange an appointment.

Thank you for reaching out to Cranstoun.