• Book appointment
  • Donate
BCHS-Logo
BCHS-Logo

Alcohol and Other Drugs self-referral form

Is this a self-referral?(Required)
Who is filling out this form?(Required)
Is the individual aware you are filling in this form?
Please answer this question if you ticked either Family or Friend to the previous question.

Your details

Name(Required)
MM slash DD slash YYYY
Address
Preferred contact method
Is an interpreter required?
Do you identify as Aboriginal or Torres Strait Islander?
Do you consent to being contacted for Intake & Assessment?(Required)
Please note: If you do not consent to being contacted, we are unable to progress with the referral process.
Do you consent to the sharing of medical information?
Please note: The sharing of your medical information may be to other internal services, other healthcare providers or approved third parties such as family or friends. If you have questions about this, please speak to Intake and Assessment.
If it is safe to do so, do you consent to BCHS leaving message when calling?(Required)