Self Referral Form

We are committed to client outcomes

Please complete and return to our Intake & Assessment Team via the submit button at the end of the form.
One of the team will contact you within 24 hours to proceed with the next step.

    Today's date:Today's date

    Your contact information:

    Family Name

    First Name

    Date of Birth:

    Preferred Name

    Preferred Pronouns



    Country of Birth

    Cultural Background

    Identifies as

    Refugee status

    Visa Status (if relevant)

    Best contact number

    Is it safe to leave a voicemail/send an SMS to this number

    Email address

    Is it safe to send correspondence to this email address?

    Preferred method of contact

    Emergency Contact's Name

    Emergency Contact's Number

    Emergency Contact's relationship to you

    Do you have Private Health Insurance

    What is your main reason for completing this form today

    Alcohol and other drug use

    Primary substance of concern

    Days of use in the past month

    Amount used per day

    Date of last use

    Usual route of administration

    Do you use any other substances

    Do you have any immediate concerns about your safety?

    What days/times are suitable for us to contact you

    Any other comments or information