Alcohol & Other Drugs referral form

Practical and therapeutic support for people who are misusing or have problematic behaviour with alcohol or other drugs.
Please complete all information required in the form fields below

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 *
Address Line 1
City
State / Province / Region
Postal Code
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.

Different Postal Address?
Post address is different to residential address

Are you of Aboriginal or Torres Strait Islander origin?

Primary carer of children under 16

Current Accommodation

Country of Birth

Preferred language

Referrer Details

Is this a self referral?

GP Details

Do you/does the person have an existing GP?

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

Click or drag files to this area to upload. You can upload up to 5 files.

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

Website