Please complete the attached self-referral form.

This form should be used to access ESRA support services if you are :

• committed  to a recovery pathway and a readiness to change
• ready to begin taking responsibility for your 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, then please call us on 01424 435318.

We will aim to call you within 2 weeks, but mostly this is sooner.

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Name *

First

Last

Name of person referring

Date of Birth *

Ethnic Origin

Gender

• Male
• Female
• prefer not to answer

Current address

Your Email *

Your phone number

Are you in recovery ?

please tell us how long you have been in recovery

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

What treatment have you received from any other organisation *

IE; CGL , the hospital, GP, rehab

Do you have a diagnose mental health condidtion *

• Yes
• No

Please can you describe your 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 your supports needs, please list what are you recovery goals you wish 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 *

• 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.

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