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Date Of Birth
Medicare Expiry Date
Type Of Benefit Received Newstart AllowanceYouth AllowanceDSPAged PensionNo Benefits Recieved
Do You Have Court Pending YesNo
What Court Date
What Are Your Charges
Are You Seeking To Be Bailed To Our Centre YesNo
Are You Seeking To Be Paroled To Our Centre YesNo
Are Your Currently On Bail YesNo
Who Is Your Solicitor
What Are Your Parole Contact Details
Are You In Jail YesNo
If You Are In Jail, Who Is The Contact Person Helping You With Your Assessment ?
If You Are In Jail, What Is The Contact Person’s Telephone Number ?
If You Are In Jail, What Is The Contact Person’s Email Address ?
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
Names Of Substances You Partake In : i.e. Alcohol, Amphetamines, Benzodiazepines (Valium), Cannabis, Cocaine, Heroin, Methadone, Prescribed Medications/Anti Depressants
Please Indicate One Most Often Used
When Did You Last Use Drugs Or Alcohol : 2 Hours, 2 Days
Are You Fully Detoxed YesNo
If Yes, Which Detox Centre
If So, What Date Did You Arrive In Detox ?
Have You Ever Applied For Entry To The Glen Before ? YesNo
If so, when ?
Did You Enter The Program ? YesNo
If no, why not ?
Have You Ever Been In Rehab Before ? YesNo
If Yes, Give Details : i.e. Which rehab, when were you there, why did you leave ?
Do You Have Any Particular Issues You May Feel You Will Need To Deal With Whilst In The Glen ?
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