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 referrals@communityresponse.ie or Download File

NOTE TO GPs AND HEALTH PROVIDERS USING "@healthmail.ie": We are whitleisted with the HSE's secure "@healthmail.ie" domain, this means that data can be securely transmitted between yourself as a "healthmail.ie" user and the domain "@communityresponse.ie". Please email referrals@communityresponse.ie 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*
Address
Phone*
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
Address
Work Phone
Mobile

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.