Use the form below to refer yourself for support.

If you are a professional making a referral on behalf of someone else, please use this referral form.

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Please select an option.(Select an option from the dropdown menu)
Your details
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Please fill in this field.(First name)
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Please fill in this field.(Surname)
Date of Birth *
Format DD/MM/YYYY
Please fill in this field.(Select date of birth)
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Must be a 10 digit number(NHS number (if known))
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Please select an option.(Select title)
What is your sex? *
Please select an option.(What is your sex?)
Is the gender you identify with the same as your sex registered at birth? *
Please select an option.(Is the gender you identify with the same as your sex registered at birth?)
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Please fill in this field.(What is you gender identity? (optional))
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Please select an option.(Search for your GP surgery. Select ‘Other’ if your GP is not listed.)
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Please fill in this field.(Please specify GP surgery )

If you do not have a Surrey GP, the expectation will be that you register with one within 6 weeks.

We will communicate with your GP regarding your care.

How may we contact you?
Contact details and consent
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Please fill in this field with a valid telephone number.(Enter preferred contact number *)
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Please fill in this field.(Enter notes (optional))
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Please fill in this field with a valid telephone number.(Enter alternative contact number)
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Please fill in this field.(Enter notes (optional))
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Please fill in this field with a valid email.(Enter e-mail address)
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Ensure email addresses match(Re-enter your e-mail address)
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Please agree to sharing your information with us.(Address)
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Please fill in this field.(Please note that our service is for Surrey residents only.)
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Please fill in this field.(Postcode)
Contact by post *
Please select an option.(Contact by post)
Interpreter required? *
Please select an option.(Interpreter required?)
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Please fill in this field.(If interpreter required, please specify language)
How can we help?
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Please fill in this field.(Please provide quantities / units of alcohol and / or type and amount of drugs currently being used)
If alcohol is the presenting problem, please complete the questions in the table below. On completion your audit score will be calculated.
Question01234
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
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Please fill in this field with a number.(Total AUDIT-C score is)
Have you previously received drug or alcohol treatment? *
Please select an option.(Have you previously received drug or alcohol treatment?)
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Please fill in this field.(If yes, please give approximate date)
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Please fill in this field.(Enter details)
Are you pregnant? *
Please select an option.(Are you pregnant?)
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Please fill in this field.(Enter details)

telephone-call 1.svg

If you require urgent telephone support, please contact Surrey Drug and Alcohol Care (SDAC) on 0808 802 5000 (or via SMS on 07537 432411), open 9am – 9pm Monday – Friday, or Narcotics Anonymous (NA) on 0300 999 1212, open 10am – midnight 7 days a week.

If you require urgent out of hours mental health support, please contact the Mental Health Crisis Helpline on 0800 915 4644

Open 24 hours a day, 7 days a week.

If you have any queries or concerns regarding the form and its use by Surrey and Borders Partnership, please contact i-access 0300 222 5932

For more information about how we use your information, click here