CAPALABA DBT REFERRAL FORM

This form is to be filled by the person interested in accessing the community for DBT skills group. We need first-hand information from the participants on how accessing Brook RED will benefit their recovery journey.

Are you completing this form on behalf of somebody you are supporting? *

YesNo

Do you have consent of the person you are supporting to complete this referral, and for Brook RED to contact them? *

YesNo

Full name or preferred name *

Postcode *

Phone *

Email Address *Please note that this is our primary method of contact

DOB *

Pronoun/s

How are you hoping DBT will benefit you? *

Are you able to arrange your own transport to and from the group? *

YesNo

How did you hear about us? *

How did you hear about us - Another Organisation *

How did you hear about us - Other *

I agree that I have read the Frequently Asked Questions *

YesNo

Brook RED offers a safe, welcoming, and recovery-focused environment, and we ask that all individuals accessing our groups or individual support contribute positively to our community.

For security please complete the check below *