If you need help completing this form, please feel free to get in touch with us.
To make a referral, please complete the form by clicking the button below. If you need any assistance please contact us.
We know reaching out for support can feel like a big step. This short form helps us understand your situation so we can contact you about joining the ADAPT Family Programme. It should take around 2–3 minutes to complete. If your loved one would like support for their own alcohol or drug use, they can refer themselves to ADAPT using the referral form here. If you are worried about someone’s immediate safety, please contact 999 or your local emergency services.
What relationship do you have with the person you are concerned about? They are my...
Please select one or more options:
(Please add as much as you feel comfortable to share)
Examples may include literacy support, language needs, ADHD or concentration needs, hearing or visual support, or anything else you would like us to consider.
We will normally contact you by email to update you about the ADAPT Family Programme. In some circumstances we may need to contact you by phone, text or WhatsApp if we need to clarify information about your referral.
