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Self-Referral

Please note: This form should NOT be completed by professionals or agencies.

If you wish to refer a person using your service then please download a referral form and risk assessment form.

Self-referral form

PROBLEM SUBSTANCES

Please only enter one substance in the Primary, Secondary and Tertiary fields. Multiple substances in the other substances field are fine.

This form collects your details in line with our privacy policy and only for the purpose of managing this referral.