Referral forms

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.

Please note, Derby Drug and Alcohol Recovery Service is for residents of Derby City only. If you live in Derbyshire please click here for help.

If you are a professional looking to refer a client, please click here

Self-Referral Form

Full Name Required

Telephone Number Required

Full address including postcode Required

Email (if you would prefer to be contacted via email)

Brief details about the reason for referral:

Date of Birth Required

Have you 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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Referral forms

Self-Referral Form

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