Referral FormDrugs and Alcohol Tear our Families ApartReferral FormAGENCY OR SELF – TO MARRIN WEEJALI Who is submitting this form?*Referral AgencyClientReferral DetailsReferred byDate Date Format: DD slash MM slash YYYY AgencyCommunity CorrectionsCourtFACSHousingJob NetworkMedical / GPMental Health ServicesOtherOfficeContact detailsEmailClient has consented to referral & information sharing with Marrin Weejali (eg: attendance, progress etc.) YES NOAttach agency consent to share information form to this referralReason for Referral:* Assess AOD and/or mental health issues and recommend appropriate treatment Grief & Loss TraumaPlease Give Details:*Client's Desired Outcome:* Address A&OD misuse Pathway to Detox/Rehab Manage SEWBClient DetailsClient name*Date of birthGenderMaleFemaleIdentityAboriginalTorres Strait IslanderAddressContact Number(s)EmailContact Issues?eg: best contact timePresenting IssuesMental Health History:Diagnosis 1Treatment Historyeg: counselling, AA/NA MeetingsAdmissionsDiagnosis 2Treatment Historyeg: counselling, AA/NA MeetingsAdmissionsRisk of Harm FactorsSuicide AttemptsSelf HarmHarm to OthersDate of Last Harm AttemptHistory of Violence and/or Sex OffenceHistory of: Violence Sex OffenceIf 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 1Date Last UsedHow OftenSubstance 2Date Last UsedHow OftenSubstance 3Date last used Date Format: DD slash MM slash YYYY How OftenLegal IssuesOffenceRelevant ordersRelevant orders/conditionsCurrent AVOsCurrent AVO*YesNoPerpetratorProtected PersonAVO details/conditions:Current MedicationsMedication 1Dosage:Prescribed forMedication 2Dosage:Prescribed forAttach Supporting DocumentsFileOptional - Send a copy of this referral to this email:
