Alcohol & Other Drugs Referral

Alcohol & Other Drugs Referral Form

Full name on Medicare Card *

Preferred name

Gender

Date of Birth *

Your email

Phone

Are there any restrictions regarding how or when we contact you? (please specify)

Residential Address *

Street address *

City *

State *

Postcode *

This service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Post address is different to residential address

Postal Address

Street address

City

State

Postcode

Are you of Aboriginal or Torres Strait Islander origin?

NoAboriginalTorres Strait IslanderBoth

Primary carer of children under 16

YesNo

Current Accommodation

Country of Birth

Preferred language

Referrer Details

Is this a self referral?

YesNo

Do you have consent to make this referral on behalf of this person?

YesNo

Name of Referrer (if NOT self-referral)

Referrer profession

Organisation

Referrer Address

Street address

City

State

Postcode

Referrer Phone

Referrer Fax

Email

GP Details

Do you/does the person have an existing GP?

YesNo

Name of GP

GP Practice and Address

Street address

City

State

Postcode

GP Phone

GP Fax

Reasons for referral

(i.e. mental & physical health, family, relationships, school, work, accommodation, justice issues, drug & alcohol). If GP, Hospital or Community Mental Health referral- please attach Mental State Examination, risk assessment, relevant discharge summary, medical history and support information.

Upload Relevant Documentation

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Substance(s) of Concern

Primary substance of concern & method of use

Secondary substance of concern & method of use

Other agencies or supports involved (please list)

Date