Pre-Assessment

Pre Assessment

Submission Date:

Full Name:(Required)

DOB(Required)

Phone(Required)

Email(Required)

M.I.N if applicable

L.S.I.R if known

Clean/Sobriety Date(Required)

Free of all drugs including alcohol

Drug of Choice

Payment/benefit type:

Payment date:

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: