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This employee referral form is designed to be completed by employers and their representatives who are seeking professional addiction treatment for an employee.

Complete the fields below. All information is held securely and data will be dealt with in accordance with our privacy policy.

About You & Your Company

Your full name:
Your job title:
Company/Organisation name:
Company address:
Company postcode:
Telephone number:
Your work email address:

About Your Employee

Employee's full name:
Employee's job title:
Employee's work location:
Nature of employee's addiction:
How is your employee funding his or her treatment?
Please provide any other pertinent information:
Have you sought your employee's consent to share with us this information?