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First Name

Last Name

Gender

Telephone

Your Email

Age

Town / Suburb

Do you have family support?
YesNo

What health service providers are you currently linked with? (eg. alcohol and other drug agencies, mental health workers, counsellors)

Do you have Private Health Insurance?
YesNo

Are you connected with Government services -Centre link?
YesNo

Do you have a health care card?
YesNo

Medical Conditions

Hepatitis CHepatits BLiver DamageDiabetesHeart Conditions
Other

Do you smoke cigarettes? YesNo
How many a day?

List allergies

Please provide a brief description of your substance use, time and frequency of use.

Do you smoke or inject substance?

Briefly describe any prior involvement in detox and/or rehabilitation programs.

List if there are any dependents.

Do you have any pending legal issues?

Other Comments