Name (of person being referred) * DOB (DD/MM/YYYY) Address * Phone Number * Does your client have convictions for any sexual offences, arson, hate crime or any other serious offences? (Please note this will not necessarily prevent admission to our service, but this information is required so that we can operate safely) If yes, please provide details: Name of referrer (if applicable) Name of agency (if applicable) Referrer's Contact Number (if applicable) Referrer's Email (if applicable) Brief summary of client's current circumstances * Include details of alcohol and substance use, accommodation status, and any other information that might be relevant to the referral * Have you/has your client detoxed from alcohol or attended a rehabilitation programme in the past? * History of alcohol and substance use (if your client is prescribed methadone, they will need to switch to a maximum 8mg of Subutex and have a reduction plan in place with their prescribing service, prior to admission) * I understand I am being referred onto an alcohol detox and rehabilitation programme. If you're completing this form on behalf of somebody else, please clarify that they understand that they are being referred onto a residential detox and rehabilitation programme before ticking this box * Transforming Choice will keep your details safe and secure, we will only use your details to contact you about your referral. We will never share your details with any third party without prior consent. Please confirm that you are happy for Transforming Choice to store your details for the purposes of this referral. * Do you wish for a copy of the referral to be sent by email? If so, please provide an email below. Otherwise, leave blank (please check your junk mail box if you don’t receive a copy of the referral form to your inbox.