1. Do you (or the person you are helping) suffer with withdrawal symptoms such as shakes, sweats, vomiting, agitation etc. when going without drugs for a period of time? (Visit our questionnaire-based assessment of physical dependency if you are in doubt, by clicking here).

Yes No

2. Would you like to receive details of your local NHS and charitable drug treatment providers (counsellors, detox and rehab centres etc)?

Yes No

3. Would you like to receive details of your local self-pay (private) drug treatment providers (counsellors, detox and rehab centres etc)?

Yes No

4. Would you like to receive details of your local NA (Narcotics Anonymous) meetings?

Yes No

5. Would you like to receive free advice on the best way forwards for you (or the person you are helping) from one of our professional advisors?

Yes No

Is this information for you or for someone you are helping?

For me For someone else

Your first name:

Your surname:

Your friend/relative's first name:

Your friend/relative's surname:

Tick the boxes below for selected treatment centres to contact you with further details by

telephone email

Your Email Address:

Your Telephone Number (one that you can be contacted on in confidence):

Postcode: * Please enter your full postcode (or that of the person you are helping) to enable us to generate details of all the relevant local services.

AddictionAdvisor^TM may wish to contact you by email in the future to up-date you on our services, and to monitor the quality of our services and of the services we refer you to. Please tick yes if this is acceptable to you:

Yes No

To help prevent automatic form submission, please type the number 7 in the following box:

Your email address will NOT be sold or spammed. All email advice services are completely confidential and completely free-of-charge.