The Society of St James
Help us help you make your life better
If you are over 18, concerned about your drug and/or alcohol use and a resident of Portsmouth, please help us to help you make your life better by filling out this form
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First Name
Last Name
Gender
Male
Female
Prefer not to say
Non Binary
D.O.B
Address Line 1
Address Line 2
City
Postcode
Contact Number
Email Address
How would you like us to contact you?
Do you have any information or communication support needs relating to a disability, impairment or sensory loss?
Yes
No
How can we best meet those needs?
Please complete these sentences where applicable:
If you need to contact me the best way is (e.g. via email instead of on the phone)…
I need information in (e.g. braille, large print)…
I communicate using (e.g. a British Sign Language (BSL) interpreter or communicator guide)….
To help me communicate I use (e.g. hearing aids or lipreading)…
Who is making this referral?
For myself
I'm referring for someone I care about
GP practice
Healthcare professional
Other professional
How can we help?
DRINK-LESS - Support to cut down drinking
Power over pain. Support for Prescribed Medications
Support for Carers and Loved Ones
Drug and Alcohol Dependancy and Support
Is there anything else you would like us to know?
Please confirm that you/the client has consented to this referral
Yes, consent given
No, consent not given
Sorry, we are unable to assist with this referral if the person has not consented to us making contact with them
Pressing submit on this form means you are giving your permission for The Society of St James to store the information you have provided and contact you in-line with
Data Protection legislation
(
https://www.gov.uk/data-protection
). We will contact you on the phone number or email provided so we can determine how we can best support you in our service.
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