ACADS Alcohol & Other Drugs Services Youth Referral Form

Age Criteria: 19 years and under
  • CLIENT DETAILS

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • CURRENT CAREGIVER/PARENT DETAILS

  • REFERRER DETAILS

  • GP DETAILS

  • REFERRAL DETAILS

  • e.g. depression/anxiety/other
  • e.g. OT, Police, Mental Health Service, Counselling Service
  • e.g. risk to self or others
  • 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