AOD CLINICAL PROGRAM REFERRAL FORM
		
LLW Office Details:  P: 1300 727 957       
E:  centralqld@liveslivedwell.org.au
	   <LLW Office:>                 	
Name of referrer: <DrName>
<DrDetails>	Date:<TodaysDate>	
Agency: <Practice><UsrAddress>
	Contact Details Phone: <UsrPhone>
Contact Details Fax:<UsrFax>	
Client Name: <PtName>	Gender: <PtSex>	
DOB: <PtDoB>	Ethnicity: <PtEthnicity>	
Client Address:            <PtAddress>                                              	Phone Number: <PtPhoneH><PtPhoneMob><PtPhoneWk>	

Reason for referral (alcohol and/or drug history and presenting issues):
<Reason for referral:>
<alcohol and/or drug history and presenting issues:>	
Summary of current offences and length of order, if appropriate:
<Summary of current offences and length of order:>
	
Previous contact with LLW:   <Previous contact with LLW: > 
Approximate Month/Year: <Previous contact with LLW - approx date:>	
Associated Risk Identified (to self, to others, from others, to community): 
  <Associated Risk Identified-to self/others/community> 	
Current DVO:  <Current DVO?>	
If yes to any of the above, please describe:
	
Client consent for the referral:
I <PtName> consent to <Practice> making the referral on my behalf to Lives Lived Well.

Client’s signature: ………………………………………………………………………

Referrer’s signature: ……………………………………………………………………

Please attach a signed Authority to Disclose/Consent for Release of Information form for this referral.