Date

Counsellor

Referrer

Referrer Contact Details

*If you were referred by a professional, please specify

**If Other, please specify

Did you find our about DAMEC via a Pamphlet? Was it....

English

Translated

Where did you obtain the pamphlet?

Client's Surname

Client's First Name

Address

Postcode

Date of Birth

Age

Gender

Male

Female

Client's Telephone Number

Client Preferred Language

Client Language Spoken at Home

Emergency Contact Person: Name

Telephone

CALD Background

Country of Birth

Health Summary

Mental Health issue information? (Tick if you/client have been diagnosed recently or past)

Yes

If Other, please comment

Client currently any receiving any Mental Health services/support?

Yes

Comment

Any recent incidents of self-harm/suicidal behaviour?

Yes

Comment

Type of Intervention Requested (please tick):

Individual

Couple

Family

Group

Reason for referral / Identified issues of concern:

Substance Abuse Summary

Primary substance of concern

Frequency of past use

Current use

Quantity of current use

Last use

Primary substance of concern

Frequency of past use

Current use

Quantity of current use

Last use

Opioid or maintenance treatment program (methadone, suboxone etc)?

Yes

If Yes, how many mls?

Does the client use Tobacco?

Yes

Has the client ever accessed / used DAMEC services previously?

Yes

Previous Clinician

Client receiving Drug and Alcohol counselling or treatment at another service?

Yes

If Yes, please comment

Please comment if applicable

Authority to Disclose Information

insert client name

authorise the disclosure, release and exchange of information between DAMEC Counselling Service and the service provider (noted above) for the purposes of any assessment, intervention or treatment provided by that agency. The effect of this authority has been explained to me and I understand the information provided will be used in the context of my case management. I hereby confirm that I will be able to participate in/commit to counselling sessions provided by DAMEC Counselling Services.

This authority is valid

from

Client Signature

Dated

Signature of Witness

Dated

Referral Details

Client's Details

Health Summary

Substance Abuse Summary

Authority to Disclose Information