ACADS Alcohol & Other Drugs Services Youth Referral Form Age Criteria: 19 years and under CLIENT DETAILSName First Last Address Street Address Address Line 2 City Contact PhoneDate of Referral* Date Format: DD slash MM slash YYYY NHIDate of Birth Date Format: DD slash MM slash YYYY EthnicityIwiGenderCURRENT CAREGIVER/PARENT DETAILSNamesPhoneREFERRER DETAILSName First Last Role/OrganisationPhoneFaxEmail 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 InformationAshburton Community Alcohol & Drug ServiceAge Criteria: 19 years and under PO Box 596, Ashburton Phone: 308 1270 Fax: 308 1245 Email: acads@xtra.co.nz