ESRA self-referral form

Your full name (required)

Date of Birth :

Ethnic origin :

Gender :

  Male     Female

Current address :

Contact email :

Contact telephone number :

Are you in recovery? (for how long) :

What substance are you in recovery from and for how long?

What treatment have they received from any a treatment organisation?

Please describe your mental health/ wellbeing?

Do you have a mental health diagnosis condition?

Thinking about your support needs, please list what are your recovery goals you wish to work towards?

Are you receiving support from any other organisation? Please describe the support you are getting and which organisation?

How did you hear about us?

Disclosure of information

  I understand the information that I have given today will be stored in a paper form as well as electronically. It has been explained to me that it will be stored securely in line with data protection policy. This information will only be stored for as long as necessary and will only be shared with your consent and in line with our safeguarding policy.