This form is safe and secure. The information you provide is confidential and protected by encryption. We will only share information with professionals outside of Change Grow Live if we think someone is at risk of harm.

We will store this referral for a short time within the secure Formstack database. We will then keep it in our own storage. Only people who need to see the referral information will have access.

Please make sure you complete any questions marked with an asterisk (*) as we need these details to complete the next steps of your referral.

Who is this referral for?*
Do you have consent from the person you are referring?*

Please only complete a referral on someone's behalf if you have their consent. If you have any questions, please give us a call on 0300 303 2866 or email us on

Date of birth*
Do you have a fixed address?*

How would you like us to contact you?*
Please select at least one option.
What do you use? (Choose all that apply)*
Do you need any assistance? For example, you might need an interpreter or have a disability

Your patient or client's details

In this section please answer all questions on behalf of the person you are referring.

Date of birth*
Does your patient or client have a fixed address?*

What do they need support with?*
How often do they typically drink?
How often do they typically use? (Answer for their main substance if they use several)
How do they typically use? (Answer for their main substance)
How would your patient or client like us to contact them?*
Please choose at least one option.

Your details

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