Shropshire Drug and Alcohol Services Referral Form

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Referrer Information

We provide free and confidential support to young people around drugs and alcohol by offering a safe, non-judgemental and confidential space to talk. We work with people on their own goals, whether that’s staying safe and healthy, making a small change or stopping completely.

This service is for you if:
  • You are under 19
  • You are aged 24 and are a care leaver
  • You are living in Shropshire
  • You would like to make some changes around your drug or alcohol use


Young person information






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Please use numbers only


Additional agencies



Young person information






DD/MM/YYYY


Please use numbers only









Please use numbers only




Young person information






DD/MM/YYYY













Please use numbers only






Please use numbers only


  • When answering about drugs and alcohol, please tick if you are currently using and if you have used them in the past
  • For every drug you have ticked, on the next page you will be asked to give us some extra information
  • If you hover over each drug with your mouse, you will see an explanation of the drug and a link to extra information
  • Ask the Young Person about every box in every section
  • When asking about substance use, tick if the YP has current use (in the last three months) AND if there is any past use. Please tick all appropriate boxes.
  • For every substance you have ticked, on the next page you will be prompted to provide additional information
  • Each substance description can be viewed by hovering over the checkboxes 
Substance Use

A drink which is a central nervous depressant and can make people feel more relaxed and euphoric, but also increases risk-taking behaviour and aggression.

A powder which is most commonly snorted. It is a stimulant which makes people feel more energetic and confident but can also cause restlessness, aggression and paranoia. Effects can last 4-8 hours.

This may be smoked, vaped, or eaten which can change the length of the effects. People may feel happy, calm and more thoughtful but also more anxious and withdrawn.

A smokable form of cocaine made by further ‘cooking’ it to make crystals. This produces a drug with quicker onset but shorter lasting effects than powder cocaine.

A powder which is most commonly snorted. It is a short acting stimulant which may make people feel more alert and happy but also over-confident which increases risks. Effects last around 30 minutes.

Unlike cannabis, these are made in a laboratory to act on the same parts of the brain but can be much stronger. Their effects can be different and synthetic cannabinoids are generally more harmful. ‘Spice’ is widely used to mean any and all synthetic cannabinoids.

Ecstasy usually refers to a pill pressed in a distinctive shape and MDMA to a crystalline powder, but both contain MDMA. It can make you feel more social and connected but people may also feel anxious during or after the experience. Effects can last 3-6 hours.

A fine brown powder that can be smoked or injected. It is a depressant which can create feelings of relaxation but also nausea and vomiting. At higher doses there are risks of slowed breathing and heart rate.

These are psychedelic drugs that are taken orally and which alter your senses and thinking. ‘Trips’ can vary from person to person but may involve clearer sounding music, more vivid colours, altered perceptions of time and space, and sensations of spirituality and connectedness. LSD effects can last 6-12 hours and magic mushrooms effects can last 4-6 hours.

A group of tranquiliser drugs, commonly found as round pills which are swallowed. However it can be difficult to determine which are real and which are counterfeits. Generally they cause drowsiness, calmness and warmth but also blackouts and short-term memory loss which increases vulnerability for users.

These are volatile substances such as butane (e.g. aerosols), petrol, and acetone, which are purposefully inhaled to get high. This can kill instantly.

A powder which is most commonly snorted. The effects depend a lot on the dose, but generally low doses can bring energy or relaxation, and higher doses can be more ‘trippy’ with out of body experiences (known as a k hole).

These are drugs designed to replicate the effects of other substances, previously known as ‘legal highs’, therefore effects vary from drug to drug.

A powder which is most commonly snorted or swallowed. It is a stimulant which can give more energy and talkativeness but also can cause a fast heart rate, anxiety, and headaches. It is sometimes said to be like MDMA but is more stimulant-like in its effects.

A colourless gas often inhaled from a balloon (hence why it is sometimes known as ‘balloons’). Effects are very short lived but can cause euphoria and relaxation, but also light-headedness and confusion.

These are drugs used to improve physical appearance and sporting performance, the most well known being anabolic steroids but includes a wide variety of different drugs with different effects and harms. Many of these drugs being sold in gyms are counterfeits or not designed for humans, which increases the risk.







Social Situation/Behaviour







Physical and Emotional Health









Activities Around Substance Use



Drug Type in more detail
No substances selected
No substances have been selected in the previous page.
Alcohol



Amphetamine



Cannabis



Cocaine



Crack



Synthetic cannabinoids



Heroin



LSD



Benzodiazepines



Solvents/gas/glue/aerosols



Ketamine



New Psychoactive Substance (NPS)



Mephedrone



Ecstasy or MDMA



Nitrous Oxide



Performance or Image Enhancing Drugs



Any other (e.g mystery pills or powders, misuse of prescribed medication)



General Health in more detail
Teeth problems

Stomach problems

Regular headaches

Difficulty sleeping

Severe sleep problems

Chronic fatigue syndrome or ME

Self neglect

Significant weight loss

Blackouts and/or memory loss

Pregnant

Seizures/Fits

Accidental/planned overdose

Psychological health in more detail
Low self-esteem

Shyness

Mild anxiety

Severe anxiety/Panic attacks

Eating disorder/change in eating  pattern

Frequently unhappy/depressed

Self-harm

Suicide attempts

Severe paranoia

Hallucinations (when not under the influence of substances)

Psychosis or schizophrenia

Criminal Involvement
At risk of involvement in the criminal justice system

Involved in criminal justice system or committing more serious crimes

Additional questions


Additional questions


No consent given
You have chosen to not provide consent. Without your consent, you will not be able to submit this form.

For further advice, please call 01743 294700

Or visit our website at wearewithyou.org.uk
You have indicated the young person has not provided consent. Without their consent, you will not be able to submit this form.

For further advice, please call 01743 294700

Or visit our website at wearewithyou.org.uk
Thank you
Once we receive your referral you will be allocated to a key worker who will be in touch to arrange your first appointment with you. We will aim to contact you within 7 days. Please take a look at the information on our website while you are waiting for us to make contact. 
Once we receive the referral, you will be notified via email. The young person will be allocated a key worker who will be in contact with them to arrange their first appointment. We will aim to contact them within 7 days. 
If you have any questions please contact us on 01743 294700 Monday to Friday 9-5pm

Contact Information