Adult referrals
Am adult person with a clipboard icon in a thought bubble.

For you, a friend or a relative

This form is for referrals for people who are no longer in high school education and require help for their drug and/or alcohol issues. If this is a referral for someone else, they must ask their consent for the referral to be made prior to filling this in.

Requirements

If you are filling in this form for someone else, please do so with the person that you are going to refer. Please remember this referral is for counselling. It is not an emergency or crisis service. If the person is expressing a wish to die and says that they have a plan of what to do, you must ensure that they attend the local Emergency Department as soon as possible.

The process we follow
  • You will receive an automated receipt for this referral
  • We will only contact you if the referral is rejected
  • Contact the service coordinator for progress updates
  • We will contact the person directly via mobile or email
  • The person needs to take responsibility for attending the counselling sessions and communicating with their counsellor
  • If they don't attend and don't contact the counsellor we will assume they no longer require our service or the time isn't quite right as yet. However a member of the team will always try to contact them to keep the door open.

Making a referral

We need the date and type of referral to begin.

Please note that we can't accept referrals from Addiction Services or FIRST on this form - these must go through Fort and Daisy.

Date of referral

We need to confirm this for our waiting list.

Date picker icon.

Is this referral for yourself?

If the answer is yes, please skip the referrer's details section and go straight to the your details section.

Referrer’s details

If you are making this referral on someone else’s behalf.

Please note that this information will be kept safe and secure in accordance with our privacy policy.

If you require information about attendance, a mandate is required.

Your details

Provide personal details of the person who requires help.

Please note that this information will be kept safe and secure in accordance with our privacy policy.

Date picker icon.
Risks, accessibility, unavailability, male or female worker requirement?
We will contact you within three weeks to arrange an appointment.

Before submitting your referral, please double-check that all required * fields are complete.

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If you need help urgently, here's a list of contacts who can help.