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Protected: referral form staging
staging
Explore ‘Protected: referral form staging’
Overview
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Draft v2 online form
Step
1
of
2
50%
Are you making this referral for yourself or someone else?
Myself
Someone else
Name of person being referred
(Required)
First
Middle
Last
Date of birth of person being referred
(Required)
Day
Month
Year
Sex (at birth) of person being referred
(Required)
Male
Female
Prefer not to say
We are asking this information so we can tailor support to your individual situation.
Do you have a fixed abode/address?
(Required)
Yes
No
Does the person being referred have a fixed abode/address?
(Required)
Yes
No
What type of address is this?
(Required)
Home
Temporary
Correspondence only
What type of address is this?
(Required)
Home
Temporary
Correspondence only
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Primary phone number of person being referred
(Required)
Please provide a contact phone number, such as a home or mobile number so that we can contact you.
Alternative phone number of person being referred
Is there another number we can reach you on? We will use this in case we cannot reach you on your primary phone number?
Email address
Preferred communication method
(Required)
Select your preferred communication method
Text message (SMS)
Email
Letter
All of the above
How would you like us to keep in touch with you? We will use your preferred communication to send you updates such as appointment reminders.
Preferred communication method
Select your preferred communication method
Text message (SMS)
Email
Letter
All of the above
How would they like us to keep in touch? We will use their preferred communication to send them updates such as appointment reminders.
Main reason for referral
(Required)
Select a substance from the list
Alcohol
Amphetamines (excluding ecstasy)
Anti-depressants
Barbiturates
Benzodiazepines
Cannabis
Cocaine (excluding crack)
Crack
Ecstasy
Hallucinogens
Heroin
Major tranquillisers
Methadone
Novel Psychoactive Substances
Other drugs
Other opiates
Prescription drugs
Solvents
We need to know this information so we know what type of support you will need from us.
Second reason for referral
(Required)
Select a substance from the list
No second drug
Alcohol
Amphetamines (excluding ecstasy)
Anti-depressants
Barbiturates
Benzodiazepines
Cannabis
Cocaine (excluding crack)
Crack
Ecstasy
Hallucinogens
Heroin
Major tranquillisers
Methadone
Novel Psychoactive Substances
Other drugs
Other opiates
Prescription drugs
Solvents
Let us know if you use another substance other than the one listed above. If you don't use a second substance, select "No second drug".
Third reason for referral
(Required)
Select a substance from the list
No third drug
Alcohol
Amphetamines (excluding ecstasy)
Anti-depressants
Barbiturates
Benzodiazepines
Cannabis
Cocaine (excluding crack)
Crack
Ecstasy
Hallucinogens
Heroin
Major tranquillisers
Methadone
Novel Psychoactive Substances
Other drugs
Other opiates
Prescription drugs
Solvents
Let us know if you use another substance other than the one listed above. If you don't use a third substance, select "No third drug".
Please provide some details about the substance use frequency and amount used
(Required)
We ask this so we know what type of support we should be offering you.
What are your goals for support and/or treatment?
(Required)
We ask this as everybody's goals are different and we can tailor support to what you want to achieve.
Preferred gender of your support worker
(Required)
Preferred gender of your support worker
Male
Female
No preference
It may not be possible to assign you a worker of your preferred gender, but if you do have a preference please let us know.
Do you have any communication needs?
(Required)
No
Yes
We ask for this information so that we know how best we can communicate with you and if any extra assistance will be required.
Please tell us what communication needs you have
(Required)
Hearing
Sight
Speech
Literacy
Translation
Other communication need
We will use this information to ensure our support considers how best we can communicate with you.
Do you have any physical health or accessibility needs you would like us to consider?
(Required)
We are asking this question so that we can assess how best we can support any extra health needs you may have.
Do you have any mental health needs you would like us to consider?
(Required)
We are asking this question so that we can assess how best we can support any extra health needs you may have.
Please read the privacy script at the bottom of this page and let us know when you have done so by checking the correct option
(Required)
I HAVE read the below statement
I HAVE NOT read the below statement
We need to ask this so that we know you are making an informed choice to access our support. If you are referring someone else, this must have been read to them and understood.
Referrer name
(Required)
First
Last
Referrer organisation/source
(Required)
Referrer email address
(Required)
Referrer phone number
(Required)
Is there any other relevant information you would like to tell us about the person you are referring?
How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times per month
2-3 times per week
4 or more times a week
How many units of alcohol do you drink on a typical day when you are drinking?
1 or 2
3 or 4
5 or 6
7, 8 or 9
10 or more
If you are unsure about alcohol units, there is a link to our alcohol units advice at the bottom of this page.
How often do you have six or more units of alcohol on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
If you are unsure about alcohol units, there is a link to our alcohol units advice at the bottom of this page.
How often during the last year have you found that you were not able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Have you or someone else been injured as a result of your drinking?
No
Yes, but not in the last year
Yes, during the last year
Has a relative or friend or doctor or another health worker been concerned about your drinking or suggested you cut down?
No
Yes, but not in the last year
Yes, during the last year
