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Drug and Alcohol Multicultural Education Centre (DAMEC)
North Sydney T: 8706 0150 | Liverpool T: 8706 0150 | Blacktown T: 8706 0150

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Counselling Service Referral Form
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DAMEC Counselling Service Referral Form

*** IMPORTANT - IF YOU HAVE BEEN REFERRED BY ANOTHER SERVICE***

By submitting this form you agree for DAMEC Counselling to disclose, release and exchange information with the service listed here. A counsellor will explain more about this at the first appointment.

Note: All questions marked * require answers.

Referral Source Details

Referral Source Referrer Telephone Fax

Client Details

First Name* Last Name* Address* Postcode* Date of Birth*

Age* Gender* Client Contact Number* OK to leave message* Yes No Emergency Contact* Preferred Language* Language Spoken at Home* Culturally & Linguistically Diverse (CALD) Background* No Yes Need for Interpreter* No Yes Country of Birth* Aboriginal / Torres Strait Islander* No Yes

Type of Intervention Requested* Individual Couple Family Group

Reason for referral / Identified issues of concern*

Substances

Complete at least one section below

Primary Substance of Concern

Frequency of Past Use

Current Use

Quantity of Current Use

Last Use

Primary Substance of Concern

Frequency of Past Use

Current Use

Quantity of Current Use

Last Use

Primary Substance of Concern

Frequency of Past Use

Current Use

Quantity of Current Use

Last Use

Has the client ever accessed/used DAMEC services previously?* Yes No

Currently receiving Mental Health or Drug and Alcohol treatment?* Yes No

Violent Offences?* Yes No If Yes Current Recent Past

Security Check

Thank you, your form has been submitted. You will hear back from us shortly.

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DAMEC acknowledges the traditional custodians of country throughout NSW and their continuing connection to land, culture and community. We pay our respects to elders past, present and future.

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