Griffith Aboriginal Medical Service
Drug & Alcohol Program
Client Referral Form	

Ph: 02 6962 0000   Fax:  02 6962 0035    e-mail:  sbarone@griffithams.org.au

REFERRER DETAILS:						Date: <<Miscellaneous:Date (short)>>
Referral source: (self/agency) <<Practice:Name>>
Name: <<Doctor:Name>> 			E-mail: <<Doctor:E-mail>>
Telephone: <<Doctor:Phone>>			Fax: <<Doctor:Fax>>			Mobile: 	
Client Name: <<Patient Demographics:Full Name>>		Gender: <<Patient Demographics:Gender>>		D.O.B: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address Preferred>>			Ph: <<Patient Demographics:Phone (Home)>>, <<Patient Demographics:Phone (Mobile)>>
Medicare No: <<Patient Demographics:Medicare Number>>			Expiry: <<Patient Demographics:Medicare Expiry Date>>
Health Care Card: <<Health Care Card and Expiry?>> 
Next of Kin: <<Patient Demographics:Next of Kin>>			Relationship: <<Patient Demographics:Next of Kin Relationship>> 
Address: <<Patient Demographics:Next of Kin Address>>			Ph: <<Patient Demographics:Next of Kin Phone>>	
CLIENT CONSENT:

Client identifies as Aboriginal/Torres Strait Islander: <<Patient Demographics:ATSI>>
Client has given consent to this referral:<<Has client given consent to this referral?>>
	
REASON FOR REFERRAL:

<<Reason for Referral>>
	
NATURE OF CURRENT ISSUE/S:

Urgent family/domestic violence issues: <<Urgent family/domestic violence issues>>

In the case of children residing with/without the client, is FaCS  involved: <<is FaCS involved with case involving children?>>

Current living arrangements: (e.g. with partner, kids, parents, single, etc.) <<Current living attangements (with partner, kids, etc)>>

Current medication: <<Clinical Details:Medication List>> 

Side effects: <<Medication side effects>>

Compliant with current treatment/medication? <<Compliant with treatment/medication?>>

Other significant issues: <<Other significant issues:>>
	
Signed by:

Client:................................................................             Referrer:………………………………..……