Health Professional Referral Form

Patient Information

GP Details

Referrer Details

Please only complete this section if the referrer is NOT a GP. (If GP practice leave blank)

Referral Information

(Please feel free to provide any further information using the space below)
If Yes – Do not proceed with this referral. Please visit the Emergency section of our website to get information on how to refer to The Crisis Hub.
If Alcohol and substance misuse are the primary problem, please visit the CGL website. You can find information about CGL on our website in the Resources section.