Adfam

First name*

Last name*

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?

Text messages

Phone calls

Leave messages (voicemail)

Email address*

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

Can we send emails?

Yes

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?

Yes

Preferred contact method

Best time to contact

GP Practice Name*

GP Practice Address*

GP Practice Town*

GP Practice Postcode*

GP Practice Phone number*

Other: please specify

Does the person with the substance use problem live in Gateshead local authority area?*

Yes

No

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.*

Referral