Digital Referral Form

Self Referral Form

Thurrock Drug and Alcohol Service
Document Title
Referral Date

DayMonthYear
Email Address Sender FT
No Reply Email
Thurrock Email
Do you live within the Thurrock area?*

YesNo

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.

Do you have a fixed address?*
What is your address?

Street Address

Street Address Line 2

TownCounty

Post Code
What is your telephone number?*
Do you have an email address?*
What is your email address?
example@example.com
How can we contact you? Please select all applicable.*

TelephoneText messageLetterEmail
What is the name of your GP surgery?
NHS number (if known)

Have you had support from a drug and alcohol service before?*
Are you getting support from any other services?*
What support are you currently receiving? *
Do you take any prescribed medication?*
What medication are you currently taking?*

What substance(s) are you currently using and need support with?*
How much are you currently drinking or using?*

What goals can we help you with?*

What time of the day is best to contact you to discuss your treatment options?*

MorningAfternoonAnytime
Should be Empty: