Online Referral - Inclusion Hants

We want to enable you to make the changes that you want to make, whether that is to reduce or completely stop your use. We can provide a team of Doctors, Nurses, Recovery Workers, Community Connectors, Peer Mentors and Recovery Coaches to help you achieve this.

Success for us is when you hit your goals and enabling you to be happy, healthy and well. We look forward to achieving this with you.

Are you a professional wanting to refer someone? Please click here

What to expect

After you have submitted your online referral, a member of our team will aim to contact you within 2 working days.

They will arrange an initial appointment with you at a time that suits you, this can be via the telephone or face-to-face.

If you are unsure about anything just ask. We are happy to answer any questions you may have.

Our services are free – you don’t have to pay for any of the support we offer.

Our services are confidential – you are in control of your information, how it is stored and if it is shared (this will be discussed fully at your initial appointment).

Self-referral form

New Referral form

First name*
Last name*
Gender*
Please select
Date of Birth*
DD slash MM slash YYYY
Address*
If you don't have a fixed address (NFA) and are receiving benefits please use the address use for your claim

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Contact number*
Email address*
Are you registered with a GP/Doctor*
- Yes
- No
GP Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Can we contact you by telephone/mobile?*
- Yes
- No
Can we say who we are by text or verbal message?*
- Yes
- No
Can we contact you by letter?*
- Yes
- No
Our service has trained volunteers, can a volunteer contact you?*
- Yes
- No
Do you have any disabilities?*
- Yes
- No
Do you have any literacy difficulties?*
- Yes
- No
Do you need an Interpreter?*
- Yes
- No
Do you drink alcohol?*
- Yes
- No
Specify how much and often*
Does your alcohol use cause you any concerns with your...*
- Physical Health
- Emotional Health
- Family
- Relationships
- Housing
- Work
- Employment
- Finances
- Illegal Activities
Do you use drugs?*
- Yes
- No
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
- Heroin
- Illicit methadone (not prescribed)
- Cannabis
- Ecstasy
- Cocaine
- Crack
- NPS (psychoactive substance)
- Solvents
- Nitrous Oxide (laughing gas)
- Ketamine
- GHB
- Amphetamins
- Anabolic steroids / performance & image enhancing drugs (PIEDs)
- Methamphetamine
- Opiates / Opioid painkillers (e.g. Tramadol)
- Fentanyl
- Other
Specify how much and often*
Does your drug use cause you any concerns with your...*
- Physical Health
- Emotional Health
- Family
- Relationships
- Housing
- Work
- Employment
- Finances
- Illegal Activities
The following questions give us the information we need to prioritise your referral.
Are you or your partner pregnant?*
Do you have any current or previous mental health concerns?*
Do you have involvement with other services? For e.g. Social Care, probation, CMHT, Health Visitor Please specify*
Do you have any physical health conditions or symptoms which are likely to require treatment? Please specify*
Do you want to tell us anything else?*
Pressing send on this form means you are giving your permission for Inclusion Recovery Hampshire 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.

New Referral form

The following questions give us the information we need to prioritise your referral.