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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