DAMEC Counselling Service Referral Form

Welcome to Drug and Alcohol Multicultural Education Centre (DAMEC) Welcome to Drug and Alcohol Multicultural Education Centre (DAMEC)

*** 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

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

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