Rotherham Online Referral Form

Complete this form to refer yourself or someone else to Rotherham Alcohol and Drug Service (provided by WithYou).

Rotherham Online referral form

Liverpool 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

What are your preferred gender pronouns? Help text




DD/MM/YYYY
Personal details of the person you are referring

Personal details of the person you are referring

What are their preferred gender pronouns? What are their preferred gender pronouns?




DD/MM/YYYY
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?

Please describe your drug and alcohol use and what help you need
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?

Please outline drug and alcohol use and reason for referral
How would this person prefer to be contacted? How would this person prefer to be contacted?



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

Your details

Referrer full name
Referrer email
What is your relationship with the person you are referring?
Do you have the permission of the person you are referring to share their personal information with us? Do you have the permission of the person you are


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