Health Professional Referral
Please complete the referral form below and the MSRS Intake Worker will contact you within 2-3 business days.

You will receive a copy of your referral via email for your records.

Sign in to Google to save your progress. Learn more
Email *
Your Name: *
Your Role/Profession: *
Your Contact Number: *
Client's Name:
Client's Date of Birth:
Client's Contact Number:
Suburb or postcode where client currently lives:
Medication(s) of Concern *
Is your client at risk of harm to self or others?
Clear selection
If yes, please provide details:
Consent Obtained for Referral *
*Please note: we can't proceed with referrals if the client hasn't provided consent. To speak with us about this, call 1800 931 101
Does your client require an interpreter?
Clear selection
How did you hear about us? *
Thank you for contacting us. The MSRS Intake Worker will contact you within 2-3 business days to discuss your referral.
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.