Contact Us Javascript must be enabled in order to complete this form Last Name * First Name Refocus Enqiry\Client Name Refocus Enqiry\Relationship to Client Self Husband/Wife Son/Daughter Friend Medical Professional Lawyer Other Phone 1 Refocus Enqiry\Gender Female Male Non Binary Other * Refocus Enqiry\Age Refocus Enqiry\Substances Alcohol Benzos Cocaine GHB Heroin Ice/Meth Ketamine LSD Other Prescription Meds Synthetics * Refocus Enqiry\Aware of Costs? Refocus Enqiry\Previous treatments Refocus Enqiry\Legal Challenges? Refocus Enqiry\Physical Health Issues? Refocus Enqiry\Mental Health Issues Refocus Enqiry\Current Medications Refocus Enqiry\Detox Required? Refocus Enqiry\Potential Client? Maybe No Yes Refocus Enqiry\Referred To: Arrow Health 9533 7888 Beyond Blue 1300 224 636 Dayhab 1 800 329 422 Direct Line 1 800 888 236 Family Drug Help 1 300 660 068 Hader 1800 883 388 Life Line 13 11 14 Malvern Private 9885 9621 Sharc 9573 1700 Sharc Yoputh 9573 1700 Sober Living 1 800 531 551 Suicide Call Back 1 300 659 467 YSAS (youth) 9415 8881 Sales\Lead status Referred Elsewhere Not Suitable Assesment Booked Sent Brochure Other Unknown Follow Up Email Address Sales\Lead source Friend Google Medical Referral Other Past Client Referral Unknown Refocus Enqiry\Call taken by Refocus Enqiry\Other Info All fields marked with a * must have a value in order to complete this form
