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 info@communityresponse.ie or download a form here.

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.


Choose Referral Programme(s)
Please tick which of the following programme(s) the service user is interested in attending:

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.