Internal Use Only	
Drug & Alcohol Service
Referral Information form 
                     
We email referrals to WNSWLHD-Dubbo-Referral@health.nsw.gov.au

MRN#	Referral Date: <TodaysDate>        	
CLIENTS DETAILS	
Surname:	<PtSurname>	Given
Name/s:	<PtFirstName> <PtMidName>	
Date of Birth:	<PtDoB>	Gender:	<PtSex>	
Contact Numbers	Ph: <PtPhoneH>
Mob: <PtPhoneMob>	Medicare No: 	<PtMCNo>          Exp: <PtMCExpiry>
<PtMCLine>	
Indigenous Status: 	<PtEthnicity>	Interpreter Required?	<Interpreter Required?>

Language: <PtLanguage Preferred>, Spoken: <PtLanguage Spoken>	
Email:	<PtEmail>	
Postal Address	<PtAddress>
	
Next of Kin:	<NOKName>	Contact Number/s of N.O.K	<NOKContact>	
Relationship:	<NOKRelation>		<NOKContact2>	

DRUG CONCERNS	
Primary Drug of Concern:   <Primary Drug of Concern:>     Quantity & Frequency:  <Quantity & Frequency>
Duration:   <Duration:>

Secondary Drug: <Secondary Drug:>    <Quantity & Frequency:>
Duration:  <Duration?>
	
REASON FOR REFERRAL: 
<REASON FOR REFERRAL:>

Appointment scheduled: <Appointment scheduled>  
<Agency?>Agency: 
Date & Time:  <Date & Time>
	
LEVEL OF RISK
History of Mental Health  <History of Mental Health>                     Homelessness: <Homelessness:>  
History of Domestic Violence: <History of Domestic Violence:>   Recent Self Harm or suicide attempt: <Recent Self Harm or suicide attempt:> 
Child wellbeing concerns: <Child wellbeing concerns:>                Recent Prison Release: <Recent Prison Release:>
Alerts or safety Issues: <Alerts or safety Issues:>                           Legal Issues: <Legal Issues:>    Court Date (If known): <Court Date (If known)> 	
I <PtFullName> (client name) understand and agree that WNSWLHD D & A will collect and hold my personal information so as to determine my eligibility for treatment.    Yes or NO      Patient signature: ______________

Verbal consent - I have discussed the proposed referrals with the client. I am satisfied that the client understands the proposed uses and disclosures and has provided their informed consent to these.

Signature: ____________________________                     Practitioner Name: <DrName>

Referring Practitioner:   <Referring Practitioner?>	
Name:	<DrName>	Provider Number	<DrProviderNo>	
Practice Name:	<Practice>	Practice Phone:	<UsrPhone>	
Practice Address:	<UsrAddress>