Friend or Family Member
Fill in this form if you are worried about a friend or family member's medication use or want to find out more information about our services.

We will contact you within two business days. You can also call our intake worker on 1800 931 101 (9am - 5pm, Mon-Fri).
Your Name: *
Your Date of Birth *
Your Phone Number: *
Your Email Address (optional):
Name of the person you are concerned about:
Your relationship to the person you are concerned about:
What are your concerns for your friend/family member?
Does your friend/family member require an interpreter? *
How did you hear about us? *
If you are in crisis or need urgent or after hours support, please contact one of these services:
Emergency services: 000

Directline: 1800 888 236

Family Drug Help: 1300 660 068

Lifeline: 13 11 14
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.