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Professional Referral Form

    PROFESSIONAL REFERRAL FORM.

    What service location would you like to refer into? (Required)

    ABOUT YOU AND YOUR ORGANISATION.

    ABOUT YOUR CLIENT.

    How should we contact your client? Select all that apply

    PhoneTextEmailLetter

    Can we contact your client at any time?

    YesNo

    Client's gender

    Client's ethnicity

    HEALTH INFORMATION.

    What does your client need help with? Select all that apply.

    Drug use supportAlcohol use supportFamily supportOther

    What substances are being used? Select all that apply

    Heroin/opiatesCocaineCrack CocaineCannabisCrystal meth/methamphetamineAmphetamine/speedAlcoholSolventsNew psychoactive substancesPrescribed medications (e.g. Benzodiazepine, Gapapentin)Other Please give details including how much and how often the substance is being used:

    Does your client have access support needs?

    Is your client is pregnant?


    Is your client is currently injecting substances.

    YesNoUnknown
    Has your client has been admitted to hospital in the last month?

    YesNoUnknown

    MAKE A REFERRAL.

    Is there anything else you feel is relevant to this referral?

    Personal information is important to us and we will keep it confidential. Occasions where we may need to share information are outlined in our privacy and confidentiality policy. You can read our privacy policy here, or alternatively you can ask for a copy from us.

    Submit this form and we will contact the referred individual to arrange an appointment.

    Thank you for reaching out to Cranstoun.

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