Anglicare Drug & Alcohol Treatment Service (ADATS) Referral Form
Anglicare will be in touch with the client within 48 hours of receiving this referral
Patient Name	<<Patient Demographics:Full Name>>	DOB	<<Patient Demographics:DOB>>	

Residential Address	<<Patient Demographics:Address Preferred Line 1>><<Patient Demographics:Address Preferred Line 2>>	

Suburb	<<Patient Demographics:Address Preferred City>>	Post Code	<<Patient Demographics:Address Preferred Postcode>>	

Email	<<Patient Demographics:E-mail>>	

Phone (mobile)	<<Patient Demographics:Phone (Mobile)>>	Phone (home)	<<Patient Demographics:Phone (Home)>>	

	
	
Assessed level of risk (please include any documentation/notes)	

Confirmation that the patient is happy for Anglicare to contact them (Client or parent/guardian if aged under 18)	

Signature		Date		
	
If the patient is aged under 18, please complete the below	

Parent/guardian name		Parent/guardian phone		

Relationship with patient <<If under 18, paren/guardian provided consent>>	

Referrers details	
	
Doctors Name	<<Doctor:Name>>	Phone	<<Doctor:Phone>>	

Practice Name	<<Practice:Name>>	

Practice Address	<<Practice:Address>>	

Would you like to be kept up-to-date on patient’s progress?	<<Keep me up to date with patient progress>>	

If yes, what is your preferred contact method? (please enter details below)  <<GP's preferred contact method>>	
	
Email	*****	Fax	*****	Phone	*****	
	
Other details or comments	

GP Signature		Date	<<Miscellaneous:Date>>	

Current medications (relevant)	
<<Clinical Details:Medication List>>