Specialist support

If you want to talk to someone about cutting down on your drinking, just complete our self referral form below and get some confidential specialist support.

Referral form

Please note - we can only provide this confidential specialist support to people living in the city of Derby (the area served by Derby City Council).

If you live outside Derby, you are still welcome to look around the Drinkwise Derby site and read our advice, use the tools and tips for cutting down and take our self-assessment quiz. For further help outside Derby, visit these sites:

Derbyshire: Derbyshire Recovery Partnership

Nottinghamshire: Change Grow Live

Staffordshire: Human Kind

Once we have received your referral form, we will aim to contact you by phone or email within 48 hours to discuss the support we can offer you.

Self-Referral Form

Full Name Required

Telephone Number Required

Full address including postcode Required

Email (if you would prefer to be contacted via email)

Brief details about the reason for referral:

Date of Birth Required

Have you previously served in the UK armed forces (including TA)?

Yes

I agree to the privacy policy

If you would like an electronic record of the information you have submitted, please enter your email address

I confirm that the email address above is correct (please tick to confirm)

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Specialist support

Referral form

Self-Referral Form

Accessibility tools