We Are With You - South Ayrshire Self Referral Form

Welcome to WithYou Drug & Alcohol Service in South Ayrshire. 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.

South Ayrshire - Self Referral Form

Patient Details

If you'd like to book an 60 minute phone appointment instead, please click on the icon below:Phone Appointment Icon

Or feel free to contact us directly on: 01292 430529

To view our full privacy policy please follow the link below

WithYou Privacy Policy 

 

DD/MM/YYYY
Sexuality
Do you consider yourself to have any physical or mental impairments? *
Presenting Needs
Contact Details
Please enter your registered GP

Consent

Do you give consent for us to contact you? *
If we call, can we say it’s We Are With You?
How do you prefer to be contacted? Please select all that apply

Next of Kin Details

Telephone number of next of kin details