Drug & Alcohol Service Referral

If you are looking for direct support and structured drug or alcohol treatment please complete the form below to make a referral.

Please note that the more information that is included on your referral, the quicker it will be processed. If too much information is missing from your referral we will need to call you to obtain this. 

If you wish to download the referral form to send in via email or post Click here. Referrals should be sent to This email address is being protected from spambots. You need JavaScript enabled to view it. or your nearest GDAS base

 

Drug & Alcohol Service Referral


Service User Details

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or Home Number

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Details of PERSON MAKING REFERRAL (if different to above)

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Socio-economic Details

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If yes please give details

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Dependents or pregnant - please enter the information for each child

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All About Me

Reason for referral:

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Primary Substance:

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Orally, inject, sniff, etc.

Secondary Substance:

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Orally, inject, sniff, etc.

Tertiary Substance

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Orally, inject, sniff, etc.

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(Childcare, female/male worker, level & frequency of support)

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In person at a GDAS office / via video call / by phone/ via online courses / other (please specify):


Health

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(if known)

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If yes please give details:

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(if yes please give details)

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Please confirm any details of intentional overdose (approx dates, substance, were you admitted to hospital?)

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(approx dates, substance, were you admitted to hospital?)

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(Hep B, Hep C, HIV, STI’s)?

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(opiate use only) (Check in date)


Criminal Activity

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(if yes please give details)

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CONTINUE TO RISK SECTION UNLESS CRIMINAL JUSTICE SERVICES – COMPLETE ADDITIONAL SECTION BELOW FOR CRIMINAL JUSTICE (Please do not use this form for DRR/ATR referrals)


Criminal Justice additional information

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(offence within the past 6 months for CJ Criteria)

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(please tick)

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(if ticked above)

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(Please send with referral)

FOLLOWING SECTIONS TO BE COMPLETED BY ALL


Risks

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(please give details)

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Emergency Contact/Next of Kin

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Additional Notes

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