ACADS Alcohol & Other Drugs Services Youth Referral Form

Age Criteria: 19 years and under

CLIENT DETAILS
Name
First Last
Address
Street Address Address Line 2 City
Contact Phone
Date of Referral*
Date Format: DD slash MM slash YYYY
NHI
Date of Birth
Date Format: DD slash MM slash YYYY
Ethnicity
Iwi
Gender
CURRENT CAREGIVER/PARENT DETAILS
Names
Phone
REFERRER DETAILS
Name
First Last
Role/Organisation
Phone
Fax
Email
Does family/caregiver know of this referral?
Does the young person know of this referral?
GP DETAILS
Name, Clinic
REFERRAL DETAILS
Reason for referral
Alcohol and drug related problems
Please describe any known mental health difficulties or symptoms
e.g. depression/anxiety/other
Other agencies involved
e.g. OT, Police, Mental Health Service, Counselling Service
Safety concerns
e.g. risk to self or others
Additional Information
Ashburton Community Alcohol & Drug Service
Age Criteria: 19 years and under

PO Box 596, Ashburton
Phone: 308 1270
Fax: 308 1245
Email: acads@xtra.co.nz

CLIENT DETAILS