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.
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Your Contact Number:
Client's Date of Birth:
Client's Contact Number:
Suburb or postcode where client currently lives:
Medication(s) of Concern
Prescription opioids (eg. oxycodone)
Over-the-counter opioids (eg. codeine)
Benzodiazepines (eg. diazepam)
Is your client at risk of harm to self or others?
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
Yes - my client has provided informed consent and would like the MSRS Intake Worker to contact them directly.
No - I do not have consent from my client to make a referral.
Does your client require an interpreter?
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.
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