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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.
What is the urgency of this referral?

Your details

Name(Required)
MM slash DD slash YYYY
Address(Required)
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?
Do you consent to attend assessment if available?
Do you consent to the sharing of medical information?
Do you consent to BCHS leaving a voice or text message when calling?
List below. Please also obtain a recent GP Patient Health Summary and submit below or email to
Including AUDIT, DUDIT, K10, ASSIST and other reports. Please provide case plans/copy of order if applicable.
Drop files here or
Max. file size: 400 MB.