Adfam@Home Referral Form

Adfam@Home is a remote support service offering one to one support sessions. Six support sessions are available to adults affected by a loved one's drug or alcohol use, and will be delivered via Zoom or telephone.

To request support, please complete the form below. We will be in touch to check out that what we can offer is appropriate for you and then, when available, we will put you in touch with a support worker to arrange your first session.

You will need to have private use of a room and an appropriate device for your sessions, and we will also discuss any previous support, personal circumstances and ask about your mental health to ensure that providing you with remote sessions is safe and suitable for you.

About you

Contact Details

We will only use this to contact you about the service you are requesting.

We will only use this to get in touch about your referral.

Please note, your postal address is required in case of emergency during your support sessions. In exceptional circumstances we may be required to call emergency services to your home. Your counsellor/support worker would only do this if they believed that there was immediate risk of harm to you or someone else at your home.

Your GP

Please note, your GP details are required in case we have serious concerns for your health and wellbeing during your programme of support. In exceptional circumstances our counsellor/support worker may contact your GP to alert them to a matter of concern or perceived (non-emergency) risk to you. This would normally be done in discussion with you and with your agreement, but in certain circumstances where it was not possible to contact you or the risk was deemed to be high, we may contact them without your agreement.


Please give details.

Please tick all that apply.

Please note - we cannot guarantee that your application will be successful. We will be in touch to talk it through with you and check that what we are offering is appropriate for you.

Adfam stores and uses personal data in line with the GDPR. We will never share your data with another organisation for any purpose. Data will be kept and used only for as long as is necessary to enable us to provide you with the support you request, and to fulfil legal and statutory obligations. For further details please see Adfam's full privacy policy.