Please list any current medication below
Please tick any drug/substance that you have used regularly
Previous treatment for drug use
Current treatment for drug use
Optimism Supported Housing expects people who have a history of alcohol abuse to be prepared to address this problem and will work with them to do so.
Daily
Weekly
Monthly
Rarely
Previous treatment for alcohol use
Current treatment for alcohol use
Optimism Supported Housing respects your confidentiality, any information provided will only be used to assist in the risk assessment, needs assessment and selection process needed to comply with our admission policy, a copy of which is available on request. This information will be kept secure and only for as long as needed and not be seen by anyone who is not involved in the above process.
If your referral is being returned via email please note that once this section has been completed, pages 8 and 9 should be printed, signed, scanned and returned with the completed referral. Please retain the original, should it be required in the future.
I give my consent under the Data Protection Act 1998 for Optimism Supported Housingto contact any relevant agencies regarding myself in the best interests of myself and the Optimism Supported Housing.
Please send your completed application form to or by email to:
[email protected]
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