North Lincolnshire - Online Self 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 Self Referral Form

Self Referral

Consent

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

Please complete our Professional's Online Referral Form, following the link below: 

Professional Online Referral Form

As you have not been given consent to share confidential information, your referral will not be processed.

Alternatively for any enquiries, you can contact our team via telephone on: 01724 857633 or you can email us on: northlincsadmin@wearewithyou.org.uk

Your personal details

Please enter DOB as DD/MM/YYYY
What are your preferred pronouns? *
Do you have internet access?
Please enter GP details if known
Have you accessed treatment before? *
Please select one option from the drop down list

As you have selected “None” for substance misuse, this referral cannot be processed. Please review your response and select the appropriate option before submitting the referral.

Alternatively for any enquiries, you can contact our team via telephone on: 01724 857633 or you can email us on: northlincsadmin@wearewithyou.org.uk

Are you suffering from any withdrawal symptoms? *
Do you feel worried or affected by gambling?
Please confirm you have read and agree to our data protection policy