North Lincolnshire - Online Professional's Referral Form

Welcome to WithYou Drug & Alcohol Service in North Lincolnshire. We will need to ask you a few short questions, but this shouldn't take you longer than a few minutes. We will then be in touch to book an initial assessment appointment.

North Lincolnshire - Drug & Alcohol Self Referral Form

Someone Else - Qs

Consent

In order to progress for enquiry are we ok to add your details to our case management system? *

As you have not been given consent to share confidential information, your referral will not be processed.

Alternatively for any enquiries, you can contact our team via telephone on: 01724 857633 or you can email us on: northlincsadmin@wearewithyou.org.uk

Personal details of the person you are referring

Personal details of the person you are referring

What are their preferred gender pronouns? *
DD/MM/YYYY
Referrer - Contact Details

Contact details of the person you are referring

Does the person you are referring have a fixed address? * Does the person you are referring have a fixed address?
No information is shared without consent.

How can we support the person you are referring?

Describe your drug and alcohol use, including what you are using, how much and for how long this has been an issue and anything else you think we need to know
How would this person prefer to be contacted? * How would this person prefer to be contacted?
Referrers Details

Your details

Do you have the permission of the person you are referring to share their personal information with us? *
Please confirm you have read and agree to our data protection policy