WithYou - Drug & Alcohol - Self Referral Form

Please tell us what they want support with: *

Alcohol Use *

How often do they drink? *

Thinking of a normal drinking day, tell us what they drink and how much? *

Have you completed an Alcohol Audit? *

Please enter the score *

What do they hope to get from We Are With You? *

Drug Use *

How often do they use drugs? *

Thinking of a normal day when using drugs, tell us what they take and how much? *

What do they hope to get from We Are With You? *

Are they registered with a GP? *

Registered GP Details: *

Please describe any known risks the person you are referring may pose to staff or others: *

Will you also be working with the person being referred and in what capacity *

We Are With You - Dumfries & Galloway Agency-Referral Form