Families of Serving Military

Referral

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*

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

Who is it that has the drug/alcohol problem?

Please tick all that apply.

Mother

Father

Brother

Sister

Son

Daughter

Other family member

Partner

Friend

Other

Ex-partner

Other: please specify

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

Does your loved one with the substance problem currently serve in the British Armed Forces?*

Yes

Please provide your loved one's service and corps, regiment, unit, brigade, battalion etc.*