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Health professionals AOD referral form

Referrer Name(Required)
Preferred contact method(Required)

Consumer details

Name(Required)
MM slash DD slash YYYY
Address(Required)
Is an interpreter required?(Required)
Has the consumer identified themselves as Aboriginal or Torres Strait Islander?(Required)
Does the consumer consent to being contacted for Intake and Assessment?(Required)
Does the consumer consent to the sharing of medical information?(Required)
Does the consumer consent to BCHS leaving a voice message or text message when calling?(Required)

Key referral information

Including AUDIT, DUDIT, K10, ASSIST and other reports. Please provide case plans/copy of order if applicable.
Drop files here or
Max. file size: 200 MB.