New Chapters Self-Referral Form

Please read notes below, and make sure you are aware of our criteria before completing this referral form.  

  • All applicants applying to the service should be aware that this is a supported house to become first and foremost drug/alcohol free. We will work with the individual and relevant agencies to ensure this will be done as comfortably as possible.

  • At this time we are unable to accept applications from individuals who are currently on the Sex Offenders Register or who have a history of arson on their Criminal Record.

  • Individuals with mental health needs will be assessed on a case-by-case basis. This is to ensure that we can manage any risk and provide adequate support. There may be some cases where it is felt that the individual’s mental health needs are too great to be managed by New Chapters at this time.


  • Prior to admission - If you need a detox from any substance, you must be engaging with your local drug service and be engaging with your key worker in order to have a reduction plan in place on the day of admission.

  • As we are a charity rehabilitation programme, we require residents to fund their stay in the first stage property with their benefits (ie Universal Credit or ESA). This is to cover a service charge, utilities, food, travel, resources and activities. You will be given a weekly allowance to buy essentials.

  • All applicants must be entitled to claim housing benefit. 

  • If you do have a tenancy, dual Housing Benefit must be in place before admission, if unsure of how to claim this, please call us!

  • Please note that New Chapters do not admit individuals on the day of referral, admission is dependent on bed space, individual suitability, completing all necessary checks and demonstration of commitment.

Privacy Statement

  • Please take the time to read our Privacy Statement to understand how New Chapters will process your personal data. 

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Full name *
Please enter today's date *
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Gender *
Date of birth *
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YYYY
Current address
If no fixed abode please state this and give care of address if applicable *
Phone number/best contact number
If this is not your own number, please give contact's details *
Email address
Please write 'none' if you do not have access to an email account
 *
Nationality *
Main spoken language *
Will you require an interpreter? *
Your Support Needs
Please identify your support needs by ticking the boxes below
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Required
Please provide a brief description of your current substance use

1. What substance?

2. How long?

3. How much?
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Please tell us what services you are already engaging with *
Required
Do you have any current, previous or pending criminal convictions? If Yes please list below including approximate date(s), any involvement/conditions from probation e.g. on licence, risk register, court orders, breeches etc. Please note that disclosing offences will not jeopardise your application, unless they include arson or sexual offences. *
Additional information
Please use box below to provide any other information you feel we need to know
 *

The information contained in this referral form is true and accurate and I consent to it being used as part of New Chapters’ assessment and risk management process. 

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