Bradford referral form

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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?*

Me Someone else

Do you have consent from the person you are referring?*

Yes No

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 01274 296023 or email Bradford.Info@cgl.org.uk.

Contact information

Do you have a fixed address?*

Yes No

Address*

Address Line 1

Address Line 2

City

Postcode

How would you like us to contact you?

Phone number*

Email address

How we can help you

Please describe your drug and/or alcohol use *

What is the reason for your referral?*

Do you need any assistance? For example, you might need an interpreter or have a disability

Your patient or client's contact details

Does your patient or client have a fixed address?*

Yes No

Address*

Address Line 1

Address Line 2

City

Postcode

How would your patient or client like us to contact them?

Phone number*

Email address

How we can support them

Description of drug and/or alcohol use and reason for referral*

Any assistance needed (eg. translation or access needs)

Your details

Full name*

Role

Agency or provider

Telephone number*

Email address