Name (required)

Gender (required)

Your Ethnicity (required)

Your Date of Birth

First line of address including house number or name:(required)

Your Town (required)

Your Borough / County (required)

Your Postcode (required)

Your Safe Mobile Number

Please Confirm Your Safe Mobile Number

Your Safe Landline Number

Your Safe Email (required)

Consent to share information discussed & agreed:
YesNo

Is the client known to other agencies?
noyesCatalysti-AccessOther

If Other, please provide details

Your Employment Status (required)

Your GP Practice (required)

Your GP Practice (required)

Alcohol Use?
YesNo

Your Alcohol Consumption?
dailyweeklyMonthlyNeverOther

If 'Other', please provide details

How much alcohol do you drink each time? (please specify):

What alcohol do you drink? (please specify):

Drug Use?
YesNo

Your Drug Consumption?
dailyweeklyMonthlyNeverOther

If 'Other', please provide details

Quantity of drug use each time? (please specify):

What drugs do you use? (please specify):

Are there others living in the home? (required)

Availability for counselling?
MorningAfternoonEvening

Additional Message

Important notice: Data Protection and GDPR 2018

In accordance with the Data Protection Act 2018 and General Data Protection Regulations (GDPR) 2018 all information provided on the referral form and in any other further contact with SDAC Telephone Counselling Service will be treated as confidential and will not be disclosed to any third party without your express consent.

Your personal information will be kept for a maximum of 5 years in case you use our service again, and then it will be securely destroyed.

However, it is important that you understand that on occasions organisations are obliged to share certain information e.g. an individual is at risk to self or others, and may need to inform services such as Local Safeguarding of Vulnerable Adults Team, Child protection Team, other staff, Services Regulator(s) or other agencies. Should this need arise the Service will make every effort to discuss this with you prior to any information shared.

You have the right to withdraw consent at any time.

Consent to share information discussed & agreed:
YesNo

I agree that SDAC Telephone Counselling Service will process my personal information:
YesNo