Self Referral Form

Fill in the referral form below, and we will get back to you as possible. If you need to talk to someone immediately please call our Freephone Helpline on 0808 802 9000.
(this number is free for all landlines and mobiles)


Your Name (required)

Sex MaleFemaleTransgender

D.O.B

Your Address (required)

Can we write to you at this address?
YesNo

Your Email (required)

Telephone (required)

where did you hear about GCA?

Ethnic Background

Prefer not to say

Asian, Asian Scottish, any other Asian British or Asian Irish

African, Caribbean or Black; African, Caribbean or Black Scottish; any other African, Caribbean or Black British or Black Irish

Gypsy/ Traveller

White

How long has drinking been a problem?

How often do you drink?

Service Required

What is the best time for an appointment?

Any further information

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