ACADS Mental Health Support and Alcohol & Other Drugs Services Youth Referral Form Age Criteria: 12 years and over CLIENT DETAILSName First Last Address Street Address Address Line 2 City Contact PhoneDate of Referral* DD slash MM slash YYYY NHI Date of Birth DD slash MM slash YYYY Ethnicity Iwi Gender Female Male Other Gender Unknown/Unspecified CURRENT CAREGIVER/PARENT DETAILS(if under 16 years of age)Names PhoneREFERRER DETAILSReferrer Self Name First Last Role/Organisation PhoneEmail Does family/caregiver know of this referral?Does the young person know of this referral?GP DETAILSName, ClinicREFERRAL DETAILSReason for referralAlcohol and drug related problemsPlease 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
