Youth Referral Form - Alcohol, Other Drugs and/or Gambling Counselling 14 years old - 17 years old

First Name *

Last Name *

Gender

Date of Birth *

Preferred Pronouns

Contact Name

Contact Number *

Relationship To Client *

Does the client identify as Aboriginal or Torres Strait Islander? *

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNo

*Interpreter Services - Amity does not cover the cost of interpretation services. If the client requires an interpreter, please arrange this prior to the appointment. Please note many interpreter charges still apply in cases of non-attendance.

Does the client consent to this referral? *

Yes No

Does the client consent to being contacted by Amity? *

YesNo

Does the client consent to the booking details of their first appointment being shared with the referrer? *

YesNo

Brief relevant history: *

Client Signature *

Clear

Print Name *

Date

Referrer's details

Name *

Agency/Practice Name *

Contact Number *

Email

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