Digital Referral Form

  • Self Referral Form

    Thurrock Drug and Alcohol Service
  • Referral Date
     / /
  • Do you 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.

     

  • 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: