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.

Please note this form is not to be used by Queensland Health MH/AOD clinicians. Please contact Adis on 1800 177 833 to discuss the needs of your client/patient.

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.