Referral Form:

• Name of person applying:*
• Date of birth:*
• Address line 1:*
• Address line 2:*
• Postcode:*
• Telephone number:*
• Email address:*
• ( i ) Please note that Emerge is only able to house single people without dependents living with them.
• Required fields:*

• Is this a self-referral?

  If no, please print name and contact details of referrer and confirm that the applicant is aware of the referral.

• Name of person referring:
• Address line 1:
• Address line 2:
• Postcode:
• Telephone number:
• Email address:

• Do you have dependency issues around alcohol?* Yes No
• Do you have dependency issues around drugs?* Yes No
• Are you currently taking any prescribed medication?* Yes No
• If yes to any of these questions, have you had any previous treatment or periods of abstinence? Please give details.
• ( i ) Please note that we are unable to consider referrals from those on scripts over 40ml methadone/day.
• Required fields:*

• Do you have any outstanding court cases?* Yes No
• Do you have any previous convictions?* Yes No
• If yes, please give brief details.
• Required fields:*

• Do you need support to develop your skills in any of the following areas?

• Ability to address substance misuse issues* Yes No
• Managing your physical health* Yes No
• Managing your mental health* Yes No
• Communication skills* Yes No
• Education, training or volunteer work* Yes No
• Goal-setting* Yes No
• Developing and repairing personal relationships* Yes No
• Daily living skills* Yes No
• Parenting or childcare* Yes No
• Required fields:*

• Please tell us how you found out about Emerge: