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Home
Program
Program Stage 1
Program Stage 2
Timetable
Success Stories
Partners
About Us
Our Mission
Our Values
Our Team
History
Annual Reports
Donate
Contact Us
Pre-
Assessment
Pre Assessment
Submission Date:
DD slash MM slash YYYY
Full Name:
(Required)
DOB
(Required)
DD slash MM slash YYYY
Phone
(Required)
Email
(Required)
M.I.N if applicable
L.S.I.R if known
Clean/Sobriety Date
(Required)
Day
Month
Year
Free of all drugs including alcohol
Drug of Choice
Payment/benefit type:
Payment date:
Month
Day
Year
Have you had a formal mental health diagnosis? Please provide details:
Are you on any medications? Please provide dosage and times:
Any Primary treatment? Please provide details of rehabilitation and detox experience:
Where are you currently living?
Physical condition/have you been hospitalised lately?
Any pending court attendances notices? Please provide details including date(s), name of court and nature of the matter.
Anything else you would like to tell us:
