Tickets & information about the Social Justice Conference – 18-20 September 2024 – are now live

Alcohol & other drugs Self Referral Form

If you are a professional, referring someone you work with for support. Please follow this link and complete our professional referral form.


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


    How should we contact you? Select all that apply (Required)


    Can we contact you at any time?


    Can we leave a voicemail?


    Gender (Required)

    Ethnicity (Required)


    What do you need help with? Select all that apply (Required)

    Drug use supportAlcohol use supportFamily supportOther

    What substances do you use? Select all that apply (Required)

    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:

    If you have completed an alcohol or drug audit, what is your score?

    Do you have access support needs e.g. mobility or interpreter requirements?

    Are you pregnant?

    Are you currently injecting substances.

    Have you been admitted to hospital in the last month?


    Is there anything else you would like to tell us?

    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 you to arrange an appointment.

    Thank you for reaching out to Cranstoun.

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