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Type Of Benefit Received Newstart AllowanceYouth AllowanceDSPAged PensionNo Benefits Recieved
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Are You Currently On Medication YesNo
If So, What Types Of Medication
Have You Ever Been Diagnosed With Any Psychological / Psychiatric Disorders ? YesNo
If So, Details Of Disorders
Do You Have Any Injuries Or Disabilities ? YesNo
If So, Details Of Injuries / Disabilities
Are You Currently Being Treated By Any Medical Practitioners ? YesNo
If So, Name, Address, Telephone Number
DRUG HISTORY INFORMATION
Name of primary substance you partake in: AlcoholAmphetaminesBenzodiazepines (Valium)CannabisCocaineHeroinMethadonePrescribed Medications/Anti DepressantsOther
When did you last use drugs or alcohol? TodayYesterdayLast weekOther
Have You Ever Applied For Entry To The Glen Before ? YesNo
If so, when ?
Do You Have Any Particular Issues You May Feel You Will Need To Deal With Whilst In The Glen ?
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Prime Minister & Cabinet, NSW Health and Dept Health & Ageing – Auspiced by Ngaimpe Aboriginal Corporation.
PO Box 5179
Chittaway Bay NSW 2261
50 Church Road
CHITTAWAY POINT NSW 2261
Tel: 02 4388 6360
Fax: 02 4388 6511