First Name
Last Name
Phone
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Are you the patient, or a family member/loved one?
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I’m the patient
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Are you looking for help specifically for alcohol use?
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Yes
Not sure, but I’m worried
Option No
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How urgent is this?
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Urgent (today / as soon as possible)
Soon (this week)
Just looking for information right now
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Does the patient have medical aid?
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Which medical aid is it? (if “Yes”)
If there is a co-payment, would you be able to manage it?
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What area are you based?
What’s the best way for us to contact you?
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WhatsApp
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Preferred language
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English
Afrikaans
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