Highlands Online Referral Form

Complete this form to refer yourself or someone else to Highland Digital Service (provided by WithYou).

Highland online referral form

Shropshire Referral form

Online referral form

To view our full privacy policy please follow the link below

WithYou Privacy Policy 

 

Who are you referring? * Who are you referring?


Your personal details

Your personal details

DD/MM/YYYY
What are your preferred gender pronouns? * Help text




Personal details of the person you are referring

Personal details of the person you are referring

DD/MM/YYYY
What are their preferred gender pronouns? * What are their preferred gender pronouns?




Contact details

Contact details

Do you have a fixed address? * Do you have a fixed address?


Contact details of the person you are referring

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?


How can we help you?

How can we help you?

Can you tell us about the alcohol or drugs you are taking, for example, how much and how often?
How would you like us to contact you? * How would you like us to contact you?




Please confirm you have read and agree to our data protection policy

To view our full privacy policy please follow the link below

WithYou Privacy Policy 

How can we support the person you are referring?

How can we support the person you are referring?

What support are you referring this person for?






For example, Psychological service, Highland Drug and Alcohol services, Social work, etc.
How would this person prefer to be contacted? * How would this person prefer to be contacted?




Your details

Your details

Referrer full name
Referrer email
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