Alcohol & Other Drugs Client Consent Form

Client Details

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.

Emergency Contact Details

Carer Details

Consent for Support

Consent to Exchange Information

YesNo
GP Services
Yes
No
Family Members
Yes
No
Mental Health Services
Yes
No
Red Cross
Yes
No
Correctional Services
Yes
No
Housing SA
Yes
No
Centrelink
Yes
No
SAPOL
Yes
No
Centacare SA
Yes
No
Anglicare SA
Yes
No
Uniting Communities
Yes
No
Uniting Country SA
Yes
No
Lutheran Community Care
Yes
No
National Disability Insurance Agency
Yes
No
Clear Signature
**This consent form is valid for 12 months