Request a Call Back

Please complete the details below for an Adis counsellor to call you.

Consent to leave message / SMS?
Do you identify as Aboriginal or Torres Strait Islander?
Do you require an interpreter?
Day preference for call
Time preference for call
Services for referral
Would you like to discuss your suitability for the Your Call Program?
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Referrers will need to receive verbal consent from the person named on the form prior to sending the form to Adis.

Are you referring a client from a Queensland Health Mental Health or Alcohol and Drug Service?

Please note: this form is not suitable for use by Queensland Health Mental Health / Alcohol and Drug clinicians. If you are seeking to refer a client to an alcohol and drug service, please contact Adis on 1800 177 833 to discuss the needs of your client. Alternatively, you can find contact details for services here

1. Referrer information

Would you like a copy of this email referral emailed to you?

2. Client information

Has the client consented to the referral?
Is it safe to announce we are calling from Adis?
Is it safe for Adis to leave a message?
Does the client identify as Aboriginal?
Does the client identify as Torres Strait Islander?
Does the client require an interpreter?
Day preference for call
Time preference for call
Services for referral
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.