Application for Orana Haven Outreach Hub Date MM DD YYYY Please tick the closest Hub Bourke Brewarrina PERSONAL DETAILS Name * First Name Last Name Gender Male Female Non Binary Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Aboriginality Aboriginal Non-Aboriginal Are you the primary carer of children under 16 Yes No LIVING ARRANGEMENTS Current accommodation type REFERRAL DETAILS Name of Referrer First Name Last Name Agency Address Address 1 Address 2 City State/Province Zip/Postal Code Country Agency Email Agency Phone (###) ### #### DRUG AND ALCOHOL HISTORY What is your drug of concern What is your method of use What other drugs have you used Marijuana Heroin Meth Amphetamines (ICE) Speed Ecstasy Methadone program BUP (Buprenorphine) Alcohol INTAKE CRITERIA Do you have any current legal matters before the court or parole board Yes No If yes, provide further detail Do you have any serious medical conditions Yes No If yes, please provide further information relevant to your condition Are you currently being treated for a mental illness or have a history of Mental Illness Yes No If yes, to Mental Illness please provide further detail Bipolar Depression Anxiety Schizophrenia Paranoia PTSD Other RISK ASSESSMENT Have you engaged in any form of self harm Yes No Your current level of self-harm / suicide risk Low Moderate Significant Extreme None I declare that the information provided in this application is true and correct to the best of my knowledge Yes No You consent to this referral and understand that you will be contacted by a representative of Orana Haven (Weigelli-Hub) Yes No Thank you!