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.

Watch a short video where Niketa explains how Drinkwise Derby can help you.

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

Your details

Name Required

Date of Birth Required

NHS No.

Address Required

Address 1

Address 2

City

State/Province

Country

Postal Code

Drinkwise Derby can only provide specialist support to people living in the city of Derby - please tick to confirm that you live in Derby Required

Yes, I live in the city of Derby

Telephone Number

Ethnicity

Any physical health problems you would like to tell us about?

Any mental health issues you would like to tell us about?

What was your score on our self assessment quiz?

Have you had treatment for an alcohol problem before?

Yes

Are you using other drugs?

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)

Was this page helpful?

Specialist support

Referral form

Your details

Accessibility tools