caniad@caniad.org.uk

Caniad Referral

You can refer yourself to Caniad by free phone 0800 085 3382 or by email to caniad@caniad.org.uk or by contacting a member of staff from our contact page.

Alternatively, if you are a professional wishing to refer someone please find our referral form below.

First Name

Last Name

Date

Email Address

Phone Number

Checkboxes

Service User

Carer

Mental Health

Substance Misuse

Please choose the options that apply to the person being referred.

Address 1

Address 2

Town

County

Post Code

Risk

Please let us know of any personal, medial or other conditions that we may need to be aware of before contacting you.

Name of referrer

Name of the person filling out this form

Disclosure

I agree that by sending this form I agree to the privacy terms set out by Hafal. All data sent via this form is only accessible and viewable by Caniad staff

View privacy terms

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Always Enabled

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Functional

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