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If you are wanting to access support from DAFS, please complete the referral form below. Once we have received your information, a member of our team will contact you within 3 working days.

Referral Form

First Name

Last Name

Phone

Address

Date of Birth

Postcode

Email

Gender

Ethnicity

What is your relationship to addicted love one?

Are you or your loved one an Armed Forces Veteran?

What type of substance is involved?

Drugs

Alcohol

Both

Prescription Drugs

For the safety of our volunteers, please disclose if there is any relevant risk infomation we should be aware of?

Risk to self

Risk to others

Risk from others

Domestic Abuse

Ill Mental Health

Child Protective Services

Ex Offender

None

If you have ticked any boxes to the above question, please provide more detail in the box below

Are there any other agencies involved with the family?

Childrens/Social services

Drug & Alcohol services

Mental Health

Probation

Other

None

IF YOU ARE REFERRING SOMEONE ELSE, PLEASE COMPLETE THE REFERRER DETAILS BELOW

Referring Agency

Referrer Name

Referrer Email

Referrer Phone

Thanks for submitting!

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