Friend or Family Member
If you've been worried about someone's medication use and would like some support, or to chat about your concerns, please fill out this form.

You can also fill out this form if you'd just like more information about our services.

We will contact you within 2-3 business days. You can also call our intake worker on 1800 931 101 (9am - 5pm, Mon-Fri).
Sign in to Google to save your progress. Learn more
Your Name: *
Your Date of Birth *
Your Phone Number: *
Your Email Address (optional):
Are you seeking help for yourself, or someone else? (if selecting someone else, please ask them to call us on 1800 931 101)
Your relationship to the person you are concerned about:
Tell us a little bit about your concerns/ what kind of support you're looking for:
Do you 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
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.