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First Name *
Date Of Birth *
What is your ethnicity?
Medicare Expiry Date
CRN Expiry Date
Type Of Benefit Received Newstart AllowanceYouth AllowanceDSPAged PensionNo Benefits Recieved
Are you currently in jail? YesNo
If Yes, which jail?
If Yes, What is your MIN#?
Do you have any current charges? YesNo
If so, when is your court date?
Do you currently have a mental health diagnosis? YesNo
If So, Details Of Disorders
Are You Currently On Medication YesNo
If So, What Types Of Medication
Do You Have Any Injuries Or Disabilities ? YesNo
If So, Details Of Injuries / Disabilities
Do you have any other medical diagnoses? YesNo
If so, what is your diagnoses and current treatment?
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 ?
Are you completing this application on behalf of the applicant? YesNo
If Yes, please provide your details (Name and contact details)
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PO Box 5179
Chittaway Bay NSW 2261
50 Church Road
CHITTAWAY POINT NSW 2261
Tel: 02 4388 6360
Fax: 02 4388 6511