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About The Buttery
Vision and Mission
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Government Supports and Partners
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Drug and Alcohol Treatment Program (DAT)
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Contact The Buttery
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Menu
About
About The Buttery
Vision and Mission
Board of Directors
Governance & Funding
Government Supports and Partners
Quality & Safety
Programs
Residential Programs
Drug and Alcohol Treatment Program (DAT)
Community Outreach Programs
Youth Programs
Family and Carer Support Program
Redress Support Service
Other Services
Veterans COPE Recovery Program
NSW CDAT
Support Us
Donate
Bequests
Volunteer
Workplace Giving
The Buttery Endowment Fund
Lived Experience Advisory Group
Resources
Blog
FAQs
Publications
Brochures
Media
Research
Events
Policies
Careers
Contact
Contact The Buttery
Complaints & Compliments
Other Alcohol & Drug Services
Donate
Participant Referral Form
Complete online below or download
file_type_word
Participant Referral Form
SECTION 1. REFERRAL DETAILS
SECTION 2. PARTICIPANT CONSENT
SECTION 3. PARTICIPANT DETAILS
SECTION 4. PARTICIPANT INFORMATION ON REFERRAL
Referral Date / Time
Staff member name
Staff member phone number
Referral organisation details
(To complete only if a referral from another organisation has been made)
Organisation name
Address
Address Line 1
Address Line 2
City
State
Postcode
Country
Select Country
Australia
Hours of operation
Name of program
Contact name
Phone
Mobile
Participant consent for referral
Yes
No
Reason for referral
Issues identified by referring agency
Any risks?
Self-harm
- Select -
High
Medium
Low
Suicidal
- Select -
High
Medium
Low
To others
- Select -
High
Medium
Low
Referral made by
- Select -
Phone
Face to face
Other (specify)
Other (if applicable)
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I understand and agree for The Buttery to receive my personal details. I understand my involvement in this process is voluntary and I may withdraw at any time. I also understand that I can withdraw my consent at any time. I give consent to share information relating to my treatment and needs.
Consent type
Verbal
Written
Date of consent
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Participant name
Reference #
Address
Address Line 1
City
State
Postcode
First Nations Country you reside in
(if applicable)
Date of birth
Phone
Mobile
Cultural background
Language spoken
Interpreter required
Yes
No
Gender
Male
Female
Other
Participant emergency contact details
First Name
Last Name
Relationship
Address
Address Line 1
City
State
Postcode
Phone
Mobile
Email
Preferred method of contact
Mail
Phone
Mobile
Email
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Current personal situation
Summary of services and treatment
Client lives
Alone
With family/carer
Other (Please specify)
Other (if applicable)
Benefits
Yes
No
If so, what type?
Education
School
University
TAFE
Other (Please specify)
Other (if applicable)
Employment
Full-time
Part-time
Casual
Seeking employment
Family and social support
Health issues
Physical
Mental Health
Medication
Lifestyle activities
Legal issues
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Submit
