Self Referral
To find out more about the Medication Support and Recovery Service, or make an appointment, please fill in the self referral form below and we will contact you within two business days.

You can also call us on 1800 931 101 (9am - 5pm, Mon-Fri) to speak to our intake worker.
Your Name: *
Your answer
Your Contact Number: *
Your answer
Your Email Address (optional):
Your answer
Your Date of Birth: *
Your answer
What medications are you concerned about?
Your answer
How did you hear about us? *
Your answer
Thanks for getting in touch. We will contact you within two business days. If you are in crisis or need urgent or after hours help, please contact one of these services:
Emergency services: 000

Lifeline: 13 11 14

Directline: 1800 888 236

Nurse on Call: 1300 60 60 24
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.