Detox Form

Are you referring yourself or are you an organisation referring a client?

Self referral
Referring a client

Referrer

Your name

First Last

Email

Personal Information

Name of person your referring

First Middle Last

Personal Information

Your Name

First Middle Last

Date of Birth

Gender

Male
Female
Other

Please specify

Address

Street Address Address Line 2 City Region Postcode Country

Your Contact Information

Landline

Mobile

Email

Substance History (latest to oldest)

Substance Use	Date	Time since last used

Please use the following space to provide any additional information or to expand on any previous section.

Data Protection Statement*

The information which you provide will be processed in accordance with the UK Data Protection Act 1998 and will be used for the following purposes: to enable Changes UK to create an electronic and paper record of your needs; to enable the support you need to be arranged; to enable Changes UK to compile statistics or to assist other organisations that support you to do so (e.g. statutory funders such as Lottery, EU etc.), provided that no statistical information that would identify you as an individual will be published, unless you give us specific consent or were we have a legal or safeguarding duty to do so. The information you provide to us will be kept and processed securely on our PSIAMS database system and all data will be held locally or in UK data centres. We will share non sensitive data with other organisations that use PSIAMS, on a need to know basis, in order to facilitate support to you; sensitive data will not be shared without your consent. If you do not consent to the storing and sharing of your data we may not be able to support you.

I agree to my information being stored and processed in the above way. (click to confirm)

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Detox Form

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