WithYou - Drug & Alcohol - Self Referral Form

Please tell us what you want support with: *

Alcohol Use *

How often do you drink? *

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

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

Drug Use *

How often do you use drugs? *

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

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

Are you registered with a GP?

Registered GP Details: *

Please tell us, what are the best days and times to contact you to arrange an appointment?

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