Referral Form

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Referral Form

Drugs and Alcohol Tear our Families Apart

AGENCY OR SELF – TO MARRIN WEEJALI

Referral Details
Referred by
Date
Date Format: DD slash MM slash YYYY
Agency
Office
Contact details
Email
Client has consented to referral & information sharing with Marrin Weejali (eg: attendance, progress etc.)
- YES
- NO
Attach agency consent to share information form to this referral
Reason for Referral
- Assess AOD and/or mental health issues and recommend appropriate treatment
Other
Please Give Details
Client's Desired Outcome
Client Details
Client name*
Date of birth
Gender
- Male
- Female
Identity
- Aboriginal
- Torres Strait Islander
Address
Contact Number(s)
Email
Contact Issues?
eg: best contact time
Presenting Issues
Mental Health History:
Diagnosis 1
Treatment History
eg: counselling, AA/NA Meetings
Admissions
Diagnosis 2
Treatment History
eg: counselling, AA/NA Meetings
Admissions
Risk of Harm Factors
Suicide Attempts
Self Harm
Harm to Others
History of Violence and/or Sex Offence
History of:
- Violence
- Sex Offence
If yes, attach further information to this form
Addiction Issues
Current Drug, Alcohol, Gambling Addictions
Substance 1
How Much
How Often
Substance 2
How Much
How Often
Substance 3
How Much
How Often
Legal Issues
Offence
Relevant orders
Relevant orders/conditions
Current AVOs
Current AVO*
- Yes
- No
Perpetrator
Protected Person
AVO details/conditions:
Current Medications
Medication 1
Dosage:
Prescribed for
Medication 2
Dosage:
Prescribed for
Attach Supporting Documents
File
Please tick the following box