Aads Referral Form - Aboriginal Alcohol And Drug Service Page 2

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Yes No
Has client recently presented to hospital due to substance related issue:
If yes please provide details:_____________________________________________________________________
____________________________________________________________________________________________
Yes No
If yes, client consents to AADS requesting hospital discharge summary:
Identified Risks:
 Self-harm / suicide ideation
 Aggression / Violence
 Drug overdose
 History of unsafe injecting practice
 STI / Blood Borne Virus (BBV)
 Pregnancy
 Harm from others
 Homeless
 Other
If risk is identified, please provide more information:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Current / Previous Mental Health issues:
__________________________________________________________________________________________________
______________________________________________________________________________________________
Current / Previous Medical issues:
__________________________________________________________________________________________________
______________________________________________________________________________________________
Other known services providing care:
Service
Contact person
Contact number
Permission to contact
 Yes  No
 Yes  No
 Yes  No
Legal issues: ____________________________________________________________
________________________________________________________________________
Please circle the Treatment Options that the client is requesting:
Individual Alcohol and Drug Counselling
Drug and Alcohol Family support counselling
Brief intervention
Harm reduction
Reduce use
Pharmacotherapy referral
Withdrawal referral
Residential referral
Advocacy / Support
Unsure client wants to discuss options
 Yes  No
Is client able to attend East Perth for appointments?
Referrer Signature: _______________________________ Client Signature: _____________________ ______________
(AADS staff only)
Appointment details
 Yes  No
Client Contacted:
Appointment date:__/__/____ Time: __:__hrs
Allocated to:  AOD Support
 Outreach
Referrer notified of outcome:  Yes  No
 Declined services:______________________________________________________
 External Referral to: ____________________________________________________
 Declined Referral: ______________________________________________________
DS Referral Form
Effective November, 2012
Page 2 of 2

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