Self Referral Form

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 enage 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 : Hastings on 01424 435318.

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

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Name
Name of person referring
Gender
please tell us how long you have been in recovery
IE; CGL , the hospital, GP, rehab
Do you have a diagnose mental health condidtion
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.
Disclosure of 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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