Self Referral

Name:

minlen1Please insert your name
Address:
Postcode:

minlen1Please insert your postcode
Telephone / Mobile:

minlen1Please insert a telephone / mobile number
Email:
Occupation:

minlen1Please insert your occupation
Work Telephone:

minlen1Please insert your work telephone
Do we have your consent to contact you during work hours:

Yes: No:
Please state Date Diagnosed:

minlen1Please insert your date diagnosed
Medication Type:

minlen1Please insert your medication type
Reason for your Referral:

minlen1Please insert your medication type
Please state other members of your family:

Name School / Employment DOB
Family History:

500 characters remaining
Please tell of any major events which have occurred within the family?

500 characters remaining
Please detail input from other Professionals/Agencies to avoid duplication of services:

500 characters remaining

Please specify the service you require by ticking one bow below:

ADD NI Parenting Programme: Please indicate preference	10.30am - 12.30pm	6.30pm - 8.30pm
Group Intervention Programme 16 - 18 years
Adult Group Intervention Programme
Individual Counselling (For Adolescents and Adults)
Art Therapy

Please note that ADD NI hold client information on a confidential database in accordance with the 1998 Data Protection Act.

Please complete all aspects of this form as incomplete applications may be rejected.

Do we have your consent to contact you during work hours:
Yes:			No:

Name	School / Employment	DOB
Please state other members of your family: