Client Name (required)

Client Date of Birth

Client Gender (required)

Client Ethnicity (required)

ADDRESS & AGENCY

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

Town (required)

Borough / County (required)

Postcode (required)

Client Safe Mobile Number

Please confirm Client Safe Mobile Number

Client Safe Landline Number

Client Safe Email (required)

Is the client with another treatment provider for substance misuse?
YesNo

EMPLOYMENT & GP PRACTISE

Client Employment Status (required)

Who is the GP (required)

Client GP Practice (required)

Does Client drink Alcohol:
YesNo

Does Client use Drugs:
YesNo

Is there any additional information the client wants us to be aware of?

Are there others living in the home? (required)

Availability for counselling?
MorningAfternoonEvening

How did the client Hear about the SDAC / Extra Notes

Volunteer Name

Volunteer date