The Society of St James
Help us help you make your life better
If you are a resident of Portsmouth, over 18 and concerned about your drug and/or alcohol use, please help us to help you make your life better by filling out this form
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Professional Referrer Details
Title
First Name
Last Name
Company Name
Position
Phone Number
Email Address
Please confirm that the client has consented to making this referral
Please work with your client to complete the questions on the following pages
What can we do to help you to make your life better?
Have you ever received any support for your drug/alcohol use before?
If you have accessed support before, what did you find useful / not so useful?
Who are the people that you can rely on? Who has made you feel understood, supported or encouraged?
Is there a parent, family member, friend or carer that you would like to be involved in your treatment?
What do you want to accomplish in your life? What are your hopes for your future or the future of your family?
When things are going well in life, what do you enjoy doing?
How would you like us to make our first contact with you?
How would you like to be addressed?
First Name
First Name
Gender
Male
Female
Prefer not to say
Non Binary
D.O.B
Your Addess
Address Line 1
Address Line 2
City
Postcode
Contact Number
Email Address
Are You Registered with a GP/Doctor?
Yes
No
Surgery Name
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)…
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.
Professional Referral
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