Alcohol & Other Drugs Referral Form

Full name on Medicare Card *

Preferred name

Gender

Date of Birth *

Email verification *

Send code

Phone Number:

Mobile

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

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.

Aboriginal or Torres Strait Islander

YesNoBothPrefer not to say

Primary carer of children under 16

YesNo

Current Accommodation

Country of Birth

Preferred language

Referrer Details

Is this a self referral?

YesNo

GP Details

Do you/does the person have an existing GP?

YesNo

Name of GP

GP Practice and Address

Street address

City

State

Postcode

Phone

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.

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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

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