Referral Form for Addiction Recovery

Referral form

Please complete this form with as much detail as possible and one of our team will contact you.

Referral form

Title

Mr

Ms

Mrs

First name

Last Name

Date of Birth

Phone

Email

Know address

Postcode

Gender

Male

Female

Not stated/Not known/Inadequately described

ATSI Status:

Aboriginal

Both Aboriginal and Torres Strait Islander origin

Torres Strait Island

Neither Aboriginal nor Torres Strait Islander origin

Not stated/Unknown

Language spoken at home:

Do you have any Dependents:

Yes

No

Number of Dependents:

Free Text

Name of GP Clinic:

GP Name and Surname (if known):

GP Phone Number:

GP Email (if known):

GP Fax (if known):

Field label

Drug Information

Primary Drug:

Method of Use:

Ingest

Eat/Drink

Inhales

Injects

Date Last Used:

Frequency (days per week) If Zero please specify

Amount & Frequency of current use:

When using this drug, in the last 12 months, the client feels:

When using this drug, in the last 12 months, the client feels:

Developed tolerance?

Yes

No

Experienced Withdrawals?

Yes

No

Withdrawal symptoms:

Other Drugs:

Client Type:

Both own and other’s alcohol or other drug use

Other’s alcohol or other drug use

Own alcohol or other drug use

Mental Health

Referral Date:

Referral Agency:

Referrer Telephone:

Notes:

Legal Concerns

Legal Concerns: Please note an automatic exclusion criteria applies for any crimes against children, sexual offending, murder/manslaughter, arson and any serious crimes of violent.

New Field:

Previous AOD history/treatment

Have you attended detox/treatment in the past? Please list below.

New Field:

Current Medical/Mental Health problems

Please provide details plus medications you need to bring with you into the program.

New Field:

Additional relevant information