We Are With You - South Ayrshire Concerned Other - Family Matters Referral Form

Welcome to WithYou Drug & Alcohol Service in South Ayrshire. We will need to ask a few short questions around your concerned other, but this shouldn't take you longer than a few minutes. We will then be in touch to book an initial assessment appointment.

South Ayrshire - Self Referral Form

Patient Details

Book an Appointment

If you'd like to book an 60 minute phone appointment instead for a concerned other, please click on the icon below:

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Consent for storing submitted data *

Yes, I give permission to store and process my data

Name: *

Date of Birth: *

Contact Details

Address: *

Town/City: *

Postcode: *

Contact Number:

Gender Identity: *

Ethnicity: *

Name of family member / friend:

Their relationship to you:

Do they live with you?

Presenting Needs

Is your loved one using drugs, alcohol or both?

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

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

Is your loved one currently receiving support/treatment? Please give details:

Any Other Additional Details: