Application for Orana Haven Rehabilitation Centre Date MM DD YYYY Do you consent to an assessment for rehabilitation with Orana Haven Yes No PERSONAL DETAILS Name * First Name Last Name Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Place of Birth Aboriginality Aboriginal Non-Aboriginal If applicable name of Mob/Nation Where is your Country; Area of Mob/Nation Allergies (Food/Medication) Referred by LIVING ARRANGEMENTS Where have you lived over the last 12 months Have you been to a rehabilitation service in the past Yes No If so, where and how long Why do you want to go to Rehab LEGAL HISTORY Are you on any bail or parole conditions (if so, please provide a copy) Yes No Parole Office Name First Name Last Name Location of Parole office (Town/City) Are there any AVO's in place (if so please provide a copy) Yes No Do you have any current Court matters Yes No if so what are they Please tick relevant status Bail application Sentencing Mention Other Not applicable Please select your legal representative arrangement ASL Legal Aid Private Not applicable Solicitor's Name First Name Last Name Are you in jail Yes No If yes, what jail are you in Do you give consent for Orana Haven staff to communicate with other third parties in regards to your application process Yes No DRUG AND ALCOHOL HISTORY Is your addiction related to Alcohol Yes No When did you have your last drink How frequently do you drink Daily Weekly Other What type alcohol do you drink Is your addiction related to drugs Yes No When was the last time you used drugs How frequently do you use drugs Daily Weekly Other What is your drug of concern What is your method of use Have you ever injected drugs Yes No If so, when What other drugs have you used Marijuana Heroin Meth Amphetamines (ICE) Speed Ecstasy Methadone program BUP (Buprenorphine) HEALTH Do you have any medical conditions or disabilities Yes No If so, please provide further information relevant to your condition Do you have a history of Mental Illness Yes No If yes, to Mental Illness please specify the type Bipolar Depression Anxiety Schizophrenia Paranoia PTSD Other Have you engaged in any form of self harm Yes No If yes, please specify any of the following Cutting Scratching Burning Throwing body on hard surface Biting Hitting / Punching self Risk taking Suicidal thoughts and behaviours I declare that the information provided in this application is true and correct to the best of my knowledge Yes No Thank you!