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Alcohol and Other Drugs self-referral form

Once you lodge your information, someone will be in contact with you to find out more about how we can assist, and to book in an appointment for a more detailed assessment if required. If you have any questions, contact us on 03 5406 1200
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.
Which of our programs are you interested in?(Required)
Please note, you can select more than one option if you wish.

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?