Digital Referral Form

Digital Referral Form

Professional Referral Form

Thurrock Drug and Alcohol Service
Document Title
Referral Date

DayMonthYear
Email Address Sender FT
No Reply Email Address
Thurrock Email Address
Does your patient live within the Thurrock area?

Support Services
Unfortunately, we can only work with individuals that live within Thurrock. 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 your service user lives in a region of Essex; please contact Open Road at the link below.

Open Road Visions | Drug & Alcohol Recovery Service | Essex & Medway https://www.openroad.org.uk/
Contact Us - Open Road Visions

If your service user lives in a region of Rainham; please contact Turning Point at the link below

https://www.turning-point.co.uk/support-we-offer/drugs-and-alcohol

Otherwise, please contact us for more information.

Substance(s) requiring support?
Description of drug and/or alcohol use and reason for referral
Are you aware of any concerns or difficulties related to gambling that may have impacted the client within the last 12 months? Please tell us.
Does the persson you are referring consent to this referral?

Referrer Details
Referrer Name

First NameSurname
Role
Agency
Telephone number
Email
Would you like to be kept updated on the outcome of your referral?

Supporting Documentation
Please upload any supporting documentation which may assist The Forward Trust with processing the referral for {yourPatients}.

Supporting documents can include medical summary information obtained from healthcare professionals and/or assessment and risk management plans from community support organisations.
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