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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Your details
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Date of Birth *
Format DD/MM/YYYY
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Must be a 10 digit number
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What is your sex? *
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Is the gender you identify with the same as your sex registered at birth? *
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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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Call *
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Text message *
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Voicemail *
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Call *
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Text message *
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Voicemail *
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Ensure email addresses match
Email *
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Contact by post *
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Interpreter required? *
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How can we help?
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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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Have you previously received drug or alcohol treatment? *
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Are you pregnant? *
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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.

Please agree to sharing your information with us.

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