Adult Referral Form

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Adult Referral Form

This form is for referrals for people who are no longer in high school education and require help for their drug and/or alcohol issues. If this is a referral for someone else, they must have given their consent for the referral to be made prior to filling this in.

UNFORTUNATELY WE CANNOT ACCEPT REFERRALS FROM ADDICTION SERVICES OR FIRST ON THIS FORM; THESE MUST GO THROUGH FORT & DAISY

Date of referral

YYYY

Is this referral for yourself? *

Yes

Does the person being referred agree to DAPL holding your information in accordance with the General Data Protection Regulations? if no client cannot receive counselling from DAPL. *

Yes I give my Consent

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