Self-referral form

If you want to talk to someone about cutting down on your drinking or drug use, just complete the self-referral form below to get some confidential specialist support.

Once we have received your referral form, we will aim to contact you by phone or email within 3 working days to discuss the support we can offer you.

Third-Party Referral Form

Referrer Full Name Required

Role/Organisation Required

Referrer Telephone Number Required

Referrer Email Required

I confirm that the person being referred has given consent for the referral and for their personal information and contact details to be shared with Derby Drug and Alcohol Recovery Service Required

I confirm that the person being referred has given consent for the referral and for their personal information and contact details to be shared with Derby Drug and Alcohol Recovery Service

I confirm that the person being referred has given consent for the information I provide to be recorded on the client's NHS record. The information will be restricted, however healthcare professionals will see that the client is open to our care Required

Brief details about the reason for referral:

I confirm that the person being referred has given consent to be contacted by Derby Drug and Alcohol Recovery Service via the contact details provided Required

I confirm that the person being referred has given consent to be contacted by Derby Drug and Alcohol Recovery Service via the contact details provided

Client Name Required

Date of Birth Required

Address Required

Address 1

Address 2

City

State/Province

Country

Postal Code

Additional referral information

Telephone Number

Email address:

Ethnicity

Are children's social care involved?

Yes

If yes, detail any additional information regarding risk here:

Has the client previously served in the UK armed forces (including TA)?

Yes

I agree to the privacy policy

If you would like an electronic record of the information you have submitted, please enter your email address

I confirm that the email address above is correct (please tick to confirm)

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Self-referral form

Third-Party Referral Form

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