Referral Form Drugs and Alcohol Tear our Families Apart Referral Form AGENCY OR SELF – TO MARRIN WEEJALI Who is submitting this form?* Referral Agency Client Referral DetailsReferred by Date DD slash MM slash YYYY AgencyCommunity CorrectionsCourtFACSHousingJob NetworkMedical / GPMental Health ServicesOtherOffice 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 referralReason for Referral:* Assess AOD and/or mental health issues and recommend appropriate treatment Grief & Loss Trauma Please Give Details:*Client's Desired Outcome:* Address A&OD misuse Pathway to Detox/Rehab Manage SEWB Client DetailsClient name* Date of birth Gender Male Female Identity Aboriginal Torres Strait Islander AddressContact Number(s) Email Contact Issues? eg: best contact timePresenting IssuesMental Health History:Diagnosis 1 Treatment History eg: counselling, AA/NA MeetingsAdmissions Diagnosis 2 Treatment History eg: counselling, AA/NA MeetingsAdmissions Risk of Harm FactorsSuicide Attempts Self Harm Harm to Others Date of Last Harm Attempt History of Violence and/or Sex OffenceHistory of: Violence Sex Offence If yes, attach further information to this formPlease Provide Details:*If Violence or Sex Offence is selected, the referral cannot be processed unless information is written in this box.Addiction IssuesCurrent Drug, Alcohol, Gambling AddictionsSubstance 1 Date Last Used How Often Substance 2 Date Last Used How Often Substance 3 Date last used DD slash MM slash YYYY How Often Legal IssuesOffence Relevant orders Relevant orders/conditions Current AVOsCurrent AVO* Yes No Perpetrator Protected Person AVO details/conditions:Current MedicationsMedication 1 Dosage: Prescribed for Medication 2 Dosage: Prescribed for Attach Supporting DocumentsFileMax. file size: 300 MB.Optional - Send a copy of this referral to this email: NameThis field is for validation purposes and should be left unchanged.
