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Are you making this referral for yourself or someone else?
Name of person being referred
Let us know if the person's preferred name is different to the name above.
Date of birth of person being referred
Gender at birth of person being referred
We are asking this information so we can tailor support to the person's individual situation.
Gender identity
We are asking this information so we can tailor support to the person's individual situation.
Do you have a fixed abode/address?
Please provide a contact phone number, such as a home or mobile number so that we can get in touch.
Is there another number we can use? We will use this in case we cannot get through on the primary phone number.
Please select all the methods you're happy for us to contact you through
How else would you like us to keep in touch with you? We will use your preferred communication to send you updates such as appointment reminders.
We need to know this information so we know what type of support you will need from us.
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".
Let us know if you use a third substance other than the two listed above. If you don't use a third substance, select "No third drug".
We ask this so we know what type of support we should be offering you.
We ask this as everybody's goals are different and we can tailor support to what you want to achieve.
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?
We ask for this information so that we know how best we can communicate with you and if any extra assistance will be required.
We are asking this question so that we can assess how best we can support any extra health needs you may have.
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
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.