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.

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

Self-Referral Form

Full Name Required

Telephone Number Required

Email Required

I give consent for my personal information and contact details to be shared with Derby Drug and Alcohol Recovery Service Required

I give consent for my personal information and contact details to be shared with Derby Drug and Alcohol Recovery Service

I give consent for the information I provide to be recorded on my NHS record. The information will be restricted, however healthcare professionals will see that I am open to DDARS care Required

I give consent for the information I provide to be recorded on my NHS record. The information will be restricted, however healthcare professionals will see that I am open to DDARS care

Brief details about the reason for referral:

I give consent to be contacted by Derby Drug and Alcohol Recovery Service via the contact details provided Required

I give consent to be contacted by Derby Drug and Alcohol Recovery Service via the contact details provided

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:

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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Self-referral form

Self-Referral Form

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