Your Name (required)

Your 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

Your Safe Landline Number

Your Safe Email (required)

Consent to share information discussed & agreed:
YesNo

Your GP Practice (required)

Your Employment Status (required)

Are you with another treatment provider for substance misuse?
YesNo

If yes, please provide details

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 Alcohol 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)

Would you like to give any further information regarding your substance misuse?
YesNo

If 'Yes', please provide details

Availability for counselling?
MorningAfternoonEvening

Volunteer Name

Volunteer date

Additional Message

Note 1: If the client is employed, is it safe to use mobile for initial contact during working hours? Or do they have a work number that counsellor can contact them on?
Note 2: This question is asked to prepare the counsellor for someone else answering the phone instead of the client.