ACADS Alcohol & Other Drugs Services Adult Referral Form CLIENT DETAILSName First Last Address Street Address Address Line 2 City Contact Phone*Date of Referral* DD slash MM slash YYYY Date of Birth DD slash MM slash YYYY NHI Ethnicity Iwi Gender Female Male Other Gender Unknown/Unspecified REFERRER DETAILSReferrer Self Name First Last Role/Organisation PhoneEmail Is the client aware of this referral?Would you like feedback on referral Other agencies involved?GP DETAILSName, ClinicREFERRAL DETAILSReason for referralCurrent substance usePlease describe any known mental health difficulties or symptomse.g. depression/anxiety/otherOther agencies involvede.g. OT, Police, Mental Health Service, Counselling ServiceSafety concernse.g. risk to self or othersAdditional InformationFile uploadAccepted file types: doc, docx, pdf, Max. file size: 50 MB.Upload assessment as a Word document or PDFAshburton Community Alcohol & Drug ServicePO Box 596, Ashburton Phone: 308 1270 Fax: 308 1245 Email: acads@xtra.co.nz
