• Residential Referral Form

  • Submission Date
     / /
    2 digit day, 2 digit month, 4 digit year
  • Time
  • Email Date Format
     / /
    2 digit day, 2 digit month, 4 digit year
  • Which service are you referring to?
  • Are you completing this application on behalf of yourself?*
  • Who are you completing this application on behalf of?*

  • Information about you

  • Information about the person you are referring

  • Sex assigned at birth
  • Date of birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  •  -
  • Format: (00000) 000-000.

  • Addiction

  • Substances or behaviours of addiction*
  • Main addiction*

  • How long have the addictive substances and/or behaviours listed above been a concern?

  • Substances and/or behaviours treatment is sought for*

  • About your addiction

    Continued

  • Alcohol

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  • What types of alcoholic drinks are typically consumed?*
  • Is alcohol causing any problems or concerns?*
  • Is the amount or frequency of alcohol use a concern?*
  • Is there concern that alcohol use may be difficult to control?*

  • Substances

  • Are any substances currently used by injection?*
  • Have any substances previously been used by injection?*
  • Has any injecting equipment ever been shared with another person?*
  • Is any opioid substitution treatment (OST), such as methadone or buprenorphine, currently being received?*
  • Please select below*
  • Is the substance use causing any problems or concerns?*
  • Is the amount or frequency of substance use a concern?*
  • Is there concern that the substance use may be difficult to control?*

  • Addictive Behaviour

  • Is the behaviour causing any problems or concerns?*
  • Is there concern that the addictive or compulsive behaviour may be difficult to control?*

  • Family

  • Is there a current or suspected pregnancy?*
  • What is the expected date of delivery?
     / /
    2 digit day, 2 digit month, 4 digit year
  • Are there any responsibilities for caring for children?*
  • Are there any children under 18?*
  • Are there any children over 18?*

  • Medical History

  • We need to know what medications are currently being prescribed. Please provide the following information of prescribed medication only. 

  • Is any medical care currently being received?*
  • Has there ever been any self-harm or attempted self-harm?*
  • Has any treatment for a mental health condition been received previously, or is any being received currently?*
  • Are there any hearing, sight or mobility difficulties or support needs?*
  • Are there any known allergies?*
  • Are there any known or suspected infections that may require additional precautions or support?*
  • Are any medical investigations, procedures or appointments currently pending?*
  • Registered with a GP*
  • Format: (00000) 000-000.

  • Relationship with food

  • Are there any concerns relating to food or eating?*
  • Has an eating disorder ever been diagnosed?*

  • Details of any other agencies currently involved.

  • Are any other organisations currently providing support, such as social care, mental health, criminal justice, or drug and alcohol services?*
    • Please enter information below 
    • Format: (00000) 000-000.
    • Please enter information below 
    • Format: (00000) 000-000.
    • Please enter information below 
    • Format: (00000) 000-000.

  • Details of any other agencies currently involved

    Continued
  • Is there any care manager involvement currently?
  • Format: (00000) 000-000.

  • Legal

  • Premature discharge planning

  • In some circumstances, treatment may end before the planned completion date. This may be requested by the person receiving treatment or determined by the treatment team, including where essential safety requirements have not been met. The following information is required to support a safe and appropriate unplanned discharge plan.

  • Is a return to the current home address planned?*

  • Please enter the address you plan to return to:

  • What transport arrangements are planned?*

  • Who should be contacted and informed of the discharge from treatment?

    • Contact 1 
    • Format: (00000) 000-000.
    • Contact 2 
    • Format: (00000) 000-000.

  • Paying for treatment

  • For help with arranging payment, please contact the Admissions Team, who can provide guidance and support.

  • Please let us know how treatment will be funded*

  • Finally

  • Should be Empty: