We Are With You - North Lincolnshire - Online 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 Referral Form

Consent

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

Yes, I give permission to store and process my data

Patient Details

Client Name *

Date of Birth *

Have you accessed treatment before? *

Yes

Full Address including Town & Postcode *

Contact Number

Do you have internet access?

Yes

Do you require any support for your first appointment, such as language interpretation or communication assistance with reading and writing?

GP Details

Are there any day's and time's you are unable to attend your appointment?

What substances are you currently concerned about?

Are you suffering from any withdrawal symptoms?

Do you feel worried or affected by gambling?

Yes, would like a referral

Yes, but would like to look into support in the future