Digital Referral Form

  • Self Referral Form

    Southend-on-Sea (STARS)
  • Referral Date
     / /
  • Do you live within the City of Southend?*

  • Support Services

  • Unfortunately, we can only work with individuals that live within the City of Southend. If you are unsure what area you fall under, please enter your postcode into the Government Local Council website linked below. Please note that we only cover areas with a local authority of Southend-on-Sea Borough Council, or Southend-on-Sea City Council.

     

    https://www.gov.uk/find-local-council

     

    If you live in Rayleigh, Hadleigh, Great Wakering, Rochford, or the surrounding area, please contact Open Road Basildon at the link below.

     

    https://www.openroad.org.uk/our-services/our-centres/basildon-centre/

     

    If you live in Grays or Thurrock, please contact Vissions Thurrock at the link below.

     

    Home - Visions - Inclusion Thurrock

     

    If you live in a region of Essex not listed above, and not in the City of Southend, please contact Open Road at the link below.

     

    Contact Us - Open Road Visions

     

    Otherwise, please contact us for more information; southend.referrals@forwardtrust.org.uk

  • What is your date of birth?*
     / /
  • What was your sex assigned at birth?*
  • Expected due date?
     - -
  • What do you use to describe your gender?*
  • What are your pronouns?*
  • Where did you hear about us?*
  • How can we contact you? Please select all applicable.*
  • How often do you drink and/or use substances?*
  • How do you use?*
  • What time of the day is best to contact you to discuss your treatment options?*
  • Should be Empty: