Confidential Substance Misuse Self-Referral Form

Address & Agency

Employment and GP Practice


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.

(Please be aware that by selecting I DO NOT you will not receive counselling from SDAC Telephone Counselling Service).