Please complete the attached self-referral form. We will aim to call you within 2 weeks, but mostly this is sooner.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastName of person referring Date of Birth *Gender *MaleFemaleprefer not to answerEthnic OriginCurrent address *Your Email *Can we send emails? *YesNoYour phone number *How can we use this phone number? *Text messagesPhone CallsLeave messages (voicemail)Preferred contact method *TextEmailPostPhoneGP Practice NameGP Practice AddressGP Practice phone numberWho is it that has the drug/alcohol problem? *MotherFatherBrotherSisterSonDaughterOther family memberPartnerEx-PartnerFriendOtherDoes the person with the substance use problem live in East Sussex? *YesNoHave you had any previous support? Please give details.Please give details of how you have been affected and why you are seeking support. *How did you hear about us? *Disclosure of information *Please x cross to say you understand the informationDisclosure 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.Submit
