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Help with alcohol use
Reducing Alcohol Harm
Help with drug use
Reducing Drugs Harm
Help available for YP alcohol use
Help available for YP drug use
Family & Carers
5 Ways to Wellbeing
Nutrition and recovery
How old are you?
18 or over
Date of birth
We can help you access your nearest service
We can speak to you about how we can help you
Can we leave a message at this phone number?
Can we contact you via email?
Preferred method of contact?
Preferred day of contact?
Preferred time of contact?
What would you like help with?
Your own drug use
Your own alcohol use
Someone else's drug use
Someone else's alcohol use
What is your reason for contacting us?
Please include any information you think would be useful
If you are completing this referral form for your own use, please select any of the substances used by you in the last 3 months
Please note, this does not include any drug prescribed to you by your doctor
Illicit methadone (not perscribed)
NPS (psychoactive substance)
Nitrous Oxide (laughing gas)
Anabolic steroids / performance & image enhancing drugs (PIEDs)
Opiates / Opioid painkillers (e.g. Tramadol)
If you selected other, please specify
Pressing send on this form means you are giving your permission for One Recovery Bucks to store the information you have provided and contact you in-line with
Data Protection legislation
. We will contact you on the phone number or email provided so we can determine how we can best support you in our service.
This field is for validation purposes and should be left unchanged.