Please complete the attached referral form. This can be completed by an organisation on your behalf.

This form should be used to access ESRA support services for people who are:

• on a committed recovery pathway and a readiness to change
• ready to begin taking responsibility for their own recovery
• ready to participate in peer support recovery groups

The majority of ESRA’s clients follow an abstinence based recovery pathway. We work with individuals at assessment to identify what the clients recovery goals are, and what is most likely to improve overall quality of life. If we feel you’re not yet ready to engage with recovery support, we will signpost you to another organisation, or work with your referrer to find the most suitable support for you at this time.

All referrals are initially sent to the hub manager. ESRA staff will contact the referrer if further information is needed to move the referral forward.

If you would like to discuss a client before referring, please call us on 01424 435318.

We aim to contact them within two weeks .

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Name of Client *

First

Last

Ethnic Origin

Gender

• Male
• Female
• prefer not to answer

Current address

Email of Client

if they have one

Client contact phone number

Client date of birth *

Are they in recovery ?

please tell us how long you have been in recovery

What substance were they using? *Alcohol onlyAlcohol and drugsDrugs onlyPrescription drugs

What treatment have you received from your organisation *

IE; CGL , the hospital, GP, rehab

Do they have a diagnose mental health condition *

• Yes
• No

Please can you describe their mental health *

If you answered yes to the previous question please tell us what condition. If you answered no but still have mental health please tell us what.

Thinking about their supports needs, please list what their recovery goals you wish work towards? *

Are they receiving support from any other organisation if so what?

How did they about us? *

Disclosure of information *

• Please x cross to say you understand the information

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.

Name of referral organisation *

Email of referer *

Telephone number of referer

Submit