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	<PtFullName>	DOB	<PtDoB>	

Residential Address	<PtStreet>	

Suburb	<PtPOCity>	Post Code	<PtPOPostcode>	

Email	<PtEmail>	

Phone (mobile)	<PtPhoneMob>	Phone (home)	<PtPhoneH>	

	
	
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, consent for Anglicare to make contact provided by:>	

Referrers details	
	
Doctors Name	<DrName>	Phone	<DrPhone>	

Practice Name	<Practice>	

Practice Address	<DrAddress>	

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

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

GP Signature		Date	<DayAndDate>	

Current medications (relevant)	
<SelectedRx>