Online Referral Form

How the referral process works: To make a referral online, please fill in the form below. You or the referee will then be contacted to arrange an assessment.

Alternatively you can call 01 4549772, email or Download File

NOTE TO GPs AND HEALTH PROVIDERS USING "": We are whitleisted with the HSE's secure "" domain, this means that data can be securely transmitted between yourself as a "" user and the domain "". Please email with your direct referral.

At the point of assessment, one of our workers will discuss appropriate options with the individual and contact will be made within a few days to confim a start date. Please note that we request that the individual is not adversely affected by alcohol before assessment.

Please indicate which of the following is of interest:

Service User Details
Service User Name*
How did you hear about our service, social media, through your GP etc??
Confirm that you/they are currently drinking alcohol?
How often and how much?

*Please Note...If you are making a referral on behalf of yourself, please ignore the Referrer details section below by entering N/A 'Not Applicable'. Remember to tick the "I consent..." tick box, tick the "I'm not a robot" security tick box and click the 'Send Referral' button.

Referrer Details
Referral Agent Name
Email Address
Work Phone

I consent (or have sought consent from my client) to being contacting by Community Response following the submision of this form. I agree to being contacted in relation to the options identified above.