Which Carers Centre are you having support from?*

Support and funding from a Carers Centre needs to be in place to access support through this form

Name of your support worker or contact at the carers centre*

You must have received funding through a Carers Trust centre to access support through this form

Have you received funding from the Carers Trust Wellbeing Fund?*

Please note, this funding is required to access Adfam support through this form

Date of birth*

Gender*

Other gender

Phone number*

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

How can we use this phone number?

Email address*

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

Can we send emails?

Address*

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.

Town*

Postcode*

Can we send letters to this address?

Preferred contact method

Best time to contact

GP Practice Name*

GP Practice Address*

GP Practice Town*

GP Practice Postcode*

GP Practice Phone number*

Have you had any previous support relating to your situation as the loved one of someone who uses drugs and/or alcohol?

Please give details

Please provide brief details of how your loved one's drug/alcohol use affects you and your reason for seeking support.*

Who is it that has the drug/alcohol problem?

Please tick all that apply.

Other: please specify