APPLY FOR THE LIVING FREE PROGRAM TAKE YOUR FIRST STEP TO LIVING FREE Step 1 of 9 11% YOUR DETAILSName(Required) Given Name Family Name Date of Birth(Required) DD slash MM slash YYYY Sex(Required)MaleFemaleTHE LIVING FREE PROGRAM IS CURRENTLY ONLY AVAILABLE FOR MEN.PLEASE CALL THE OFFICE ON 8165 5399 TO FIND OUT WHERE YOU CAN RECEIVE HELP. WHERE DO YOU LIVE?Are you currently homeless?(Required) Yes No How long have you been homeless?(Required)Less than a year1-2 Years2-5 Years5+ YearsAddress(Required) Address Suburb Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaOutside Australia State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country OTHER DETAILSMobile Email Country of Birth(Required) AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Indigenous Status(Required)Aboriginal but not Torres Strait Islander originTorres Strait Islander but not Aboriginal originBoth Aboriginal and Torres Strait Islander originNeither Aboriginal nor Torres Strait Islander originNot stated/inadequately describedRelationship StatusSingleMarriedDe FactoSeparatedDivorcedWidowedDo you have a photo of yourself?Accepted file types: jpg, png, pdf, Max. file size: 8 MB.Do you hold a Driver's License?(Required) Yes No If yes, this will be required during the next stage of the intake process.Do you have a current Medicare Card?(Required) Yes No If yes, this will be required during the next stage of the intake process. EMERGENCY CONTACTEmergency Contact Name Emergency Contact First Name Emergency Contact Last Name Emergency Contact RelationshipSpouseParentChildSiblingFriendDoctorPastorSupport WorkerEmergency Contact Support Agency Name Emergency Contact Church Name Emergency Contact Surgery/Practice Name Emergency Contact Address Address Suburb Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaOutside Australia State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Mobile Emergency Contact Email OTHER CONTACTThis will be an authorised person who you will be able to communicate with whilst in the program.Other Contact Add Other Contact Other Contact Name(Required) Other Contact First Name Other Contact Last Name Other Contact Relationship(Required)SpouseParentChildSiblingFriendDoctorPastorSupport WorkerOther Contact Support Agency Name(Required) Other Contact Church Name(Required) Other Contact Surgery/Practice Name(Required) Other Contact Address Address Suburb Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaOutside Australia State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Other Contact Mobile(Required) Other Contact Email(Required) EDUCATION HISTORYWhat is the highest level of education that you have obtained? School (Year 1-12) TAFE Certificate or Diploma Bachelor's Degree Post-Graduate Degree Other Other Education(Required) Do you have any difficulties reading and writing English? Yes No Do you have any learning difficulties? Yes No Please describe any other leaning difficulties you may have POINTS OF ADDICTIONHow long have you been using?(Required)Less than a month1-6 months1-3 yearsOver 3 yearsI have never usedWhat is your principal drug of concern?(Required)AlcoholAmphetamineBarbiturates, necCannabisCigarettesOpioids, necAASAbilifyAcetazolamideAcetohexamideAcetoneAcetyl-alpha-methylfentanylAcetylsalicylic acidAcidAcompliaActacodeActifedActrapidAdamAdipex PAdormixAdvilAerosolAerosol deodorantAerraneAir freshenerAirplane glueAlcoholAlcohols, necAlcohols, necAldactoneAldazineAldosterone AntagonistAlepamAlertonicAlfentanilAliphatic Hydrocarbons, necAlka-SeltzerAllegronAlodormAloinalpha-methylfentanylAlpha-methylthiofentanylAlphaprodineAlprazolamAlprazolamAltitudeAlyraneAmbienAmbien CRAMFAmfepramoneAmilorideAmiloride hydrochlorideAmisulprideAmisulpride 400Amisulpride SandozAmisulpride WinthropAmitriptylineAmitriptyline hydrochlorideAmitrolAmizideAmphetamineAmphetamine AnaloguesAmphetamine sulfateAmphetamines, necAmphetamines, necAmylAmyl nitrateAmylobarbitoneAnabolic Agents and Selected Hormones, nfdAnabolic Androgenic Steroids, necAnabolic Androgenic Steroids, nfdAnabolic steroidsAnaesthetics, necAnafranilAnalgesics, nfdAnamorphAnapolon 50AnatensolAndriolAndrobolAngel dustAngel's trumpetAnileridineAntenexAntidepressantsAntidepressants and Antipsychotics, nfdAntifreezeAntikaliureticsAntiperspirantAntipsychoticsAPL InjectionApo-RisperidoneAprinoxAquaearArecolineArimaAripiprazoleAromatic Hydrocarbons, necAropaxAsenapineAsmolAspalaginAspirinAsproAstrix 100AtivanAtosilAtrobelAtrobel ForteAtropineAtropine sulfateAtropinic alkaloidsAtypical Antipsychotics, necAurorixAvaAvomineAwaBaeocystinBalsa wood cementBarbaloinBarbsBaseBDMPEABelladonnaBelladonna alkaloidsBenadrylBendrofluazideBenniesBenzedrineBenzeneBenzodiazepines, necBenzodizepines, necBenzosBenzylpiperazineBerotecBeta ketoneBeta2 Agonists, necBetelBetel nutBexBidiBig grinBike tyre repair glueBisacodylBKBlack beautiesBlottersBlowBlue meaniesBoldenoneBoldenone undecylenateBoltsBricanylBrietalBrietal sodiumBromazepamBromochlorodifluoromethaneBromo-DMABrufenBudsBufferinBufotenineBugesicBumetanideBuprenorphineBuprenorphineBuprenorphine hydrochlorideBurinexBuscopanBusinessman's lunchButaneButaneButobarbitoneButorphanolButorphanol tartrateButylButyl nitrateButyrophenonesBZPCCafergotCaffeineCandyCannabinoid agonistsCannabinoid agonistsCannabinoid antagonistsCannabinoidsCannabinoidsCannabinoids and Related Drugs, necCannabinoids and Related Drugs, necCannabisCannabis resinCapadexCarbon tetrachlorideCarbritalCarbutamideCardiprinCarfentanylCartiaCasanthranolCascaraCastor oilCatCathineCathinoneCathinone analoguesCathinones, necCesametCharlieChewing tobaccoChina whiteChlormethiazoleChlorodifluoromethaneChloroformChloropropamideChlorothiazideChlorpromazineChlorpromazine hydrochlorideChlorthalidoneChlotrideChop chopChorionic gonadotrophinCigarillosCigarsCipramilCitalopramCitalopram hydrobromideClarinaseClenbuterolClobazepamClomipramineClomipramine hydrochlorideClonazepamClonazepamClopineClopixolClostebolCloSynClozapineClozarilCoca leafCoca pasteCocaineCocaineCocaine hydrochlorideCodalginCodalgin ForteCodapaneCodeineCodeineCodeine phosphateCodiphenCodisCodralCodral ForteCokeConcentrate of poppy strawCorrection fluid thinnerCorrection fluidsCorticotrophinCP 50,556-1CP 55,940CrackCrack cocaineCrankCrystalCrystal methCrystalline methylamphetamine hydrochlorideCyclobarbitoneCyclohexamineCyclohexyl nitrateCyclopenthiazideDamixanDaonilDapa-TabsDaranideDark angelDaturaDBZPDeadly nightshadeDeathDecaDeca-DurabolinDegreaserDegreasing agentsDehydroepiandrosteroneDemazinDeodorantDeptranDesipramine hydrochlorideDETDexamphetamineDexamphetamineDexamphetamine sulfateDexiesDextroamphetamineDextromoramideDextromoramide tartrateDextropropoxypheneDextropropoxyphene hydrochlorideDextropropoxyphene napsylateDHEADiabineseDiacetylmorphineDia-ChekDiamicronDiamorphineDiamoxDiazemulsDiazepamDiazepamDibenzylpiperazineDichloromethaneDichlorphenamideDichlotrideDiethylcathinoneDiethylpropionDiethylpropion hydrochlorideDiethyltryptamineDi-GesicDihydrocodeineDihydrocodeinoneDihydrohydroxycodeinoneDihydromorphineDimetappDimethylheptylpyranDimethyltryptamineDiphenoxylateDiphenoxylate hydrochlorideDipravanDisprinDisprin ForteDiuretics, necDMAD-methDMHPDMTDOBDocusateDOETDOIDolasedDoloxeneDOMDoneDonnagelDonnalixDonnatabDopeDothepDothiepinDothiepin hydrochlorideDownersDoxepinDoxepin hydrochlorideDoxylamineDoxylamine succinateDriveDrnabinolDroleptanDronabinolDroperidolDrostanoloneDry cleaning agentsDuceneDurabolinDuratestonDurogesicDuromineDyazideDymadonDymadon ForteDynabolEEcgonineEckieEcstasyEcstasyEdecrilEdularEfexorEformoterolEformoterol fumarate dihydrateElectronic cigaretteElemicinEndepEndoneEnduronEnfluraneEphedra Alkaloids, necEphedrineEphedrine hydrochlorideEphedrine sulfateEphedroneEPOEpsom saltErgodylErocapErythropoietinEstroxynEthacrynic acidEthanolEthanolEthcathinoneEthraneEthyl acetateEthyloestrenolEthylproprionEticyclidineEugluconEuhypnosEveExtreme beansFantasiaFarganFarganesseFastinFenoterolFenoterol hydrobromideFentanylFentanylFentanyl analoguesFentanyl citrateFiornalFire extinguisherFire extinguisher propellantFlipiperazineFluanxolFlunitrazepamFluoperazineFluothaneFluoxetineFluoxetine hydrochlorideFluoxymesteroneFlupenthixolFlupenthixol decanoateFluphenazineFluphenazine decanoateFluphenazine hydrochlorideFluvoxamineFluvoxamine maleateFly sprayForadileForthaneFortralFospropofolFrenzyFrisiumFrusehexalFrusemideFrusemide sodiumGamma-butyrolactoneGamma-butyrolactoneGamma-hydroxybutyrateGamma-hydroxybutyrateGamma-hydroxybutyric acidGBHGBLGearGenotropinGenoxGHBGHB type drugs and analogues, necGHB Type Drugs and Analogues, necGlassGlibenclamideGliclazideGlimelGlipizideGlueGoeyGolden topsGrassGrievous bodily harmGrinGrowth hormoneGuaranaGunjaHHair sprayHalcionHaldolHaldol decanoateHalogenated Hydrocarbons, necHaloperidolHalotestinHalothaneHammerHarmalineHarmarla alkaloidsHarmineHashHash OilHashishhCGHeadsHemineurin MHerbal ecstasyHeroinHeroinHerron BlueHexanehGHHGHHomebakeHormonesHorseHorse tranquillizerHU-210HumalinHuman Chorionic GonadotrophinHuman Growth HormoneHumatropeHumatro-PenHummaHydreneHydrochlorothiazideHydrocodoneHydromorphoneHydrozideHygrotonHyoscineHypnodormHypnogenHypnovelHypurin IsophaneHypurin NeutralIbogaineIbuprofenIbuprofen lysineIceIGF-1IloperidoneImipramineImipramine hydrochlorideImovaneInadequately describedIndapamideInsigInsulinInsulin-like growth factorIonaminIso-butyl-propanoic-phenolic acidIsoelemicinIsofluraneIsonipecaineIsopropanolIsotard MCIsraeli'sIvedalIvegaJeffJimsonweedJuiceJunkKalmaKalurilKandiKapanolKatKavaKava KavaKava lactonesKetajectKetalarKetamineKetamineKetamine hydrochlorideKetavetKetoneKhatKidi-speedKwellsLAAMLacquer thinnerLactuloseLarapam SRLargactilLasixLaughing gasLaxativesLegal XLemsipLente MCLeopard's bloodLergiganLerivonLevo-alpha-acetylmethadolLevo-alpha-acetyl-methadol hydrochlorideLevomethadyl acetate hydrochlorideLevonantradolLevorphanolLevothyroxin sodiumLexotanLighter fluidLioranLiquid ELiquid ecstasyLiquid paperLiquid redLiquid XLithicarbLithiumLithium carbonateLofenoxalLogicinLomotilLonavarLoop diurecticsLorazepamLovanLove drugLSALSDLudesLuminLusedraLuvoxLysergic acidLysergic acid amideLysergic acid diethylamideMagic mushroomsMagnesium citrateMagnesium hydroxideMagnesium sulphateMajikMandiesMandrakeMandrake rootMandraxMannitolMAO inhibitorMAOIMarijuanaMarinolMaryjaneMashedMBDBMBZPmCPPMDAMDBDMDBZPMDEMDEAMDMMDMAMDOHMecloqualoneMede-PrepMelipramineMelizideMellerilMelperoneMeOPPMeperidineMeperidine analoguesMersyndolMersyndol ForteMescalineMestanoloneMesterolonemeta-ChlorophenylpiperazineMetermineMethMethadoneMethadoneMethadone hydrochlorideMethamphetamineMethamphetamineMethamphetamine analoguesMethandienoneMethandriolMethandriol dipropionateMethanolMethanolMethaqualoneMethcathinoneMethenoloneMethenolone acetateMethenolone enanthateMethoMethohexitoneMethohexitone sodiumMethoxyfluraneMethychlothiazideMethyl butyl ketoneMethyl chlorideMethyl ethyl ketoneMethylamphetamineMethylamphetamine hydrochlorideMethylandrostanoloneMethylated spiritsMethylbenzylpiperazineMethyldihydromorphineMethylene chlorideMethylenedioxybenzylpiperazineMethylenedioxybutylamineMethylenedioxyethylamphetamineMethylephedrineMethylfentanylMethylphenidateMethylphenidate hydrochlorideMethylphenobarbitoneMethylpseudoephedrineMethylthioamphetamineMetoponMianserinMianserin hydrochlorideMiboleroneMicrodotMidamorMidazolamMidorideMigralMilk of magnesiaMinidiabMiraaMiscellaneous DrugsMixtardMMDAMoclobemideModecateModel glueModizideModureticMogadonMonoamine Oxidase Inhibitors, necMonotardMorning glory seedsMorphMorphalginMorphineMorphineMorphine hydrochlorideMorphine methobromideMorphine sulfateMorphine tartrateMPPPMPTPMS ContinMTAMullMurelaxMyristicinMysleeN,N-diethyltryptamineN,N-dimethyltryptamineN,N-tetramethylenetryptamineN-[alpha-methyl-3,4-(methylendioxy)phenethyl]hydroxylamineNabiloneNail polish removerNaloxoneNaloxone hydrochlorideNaltrexoneNandroloneNandrolone cypionateNandrolone decanoateNandrolone laurateNandrolone undecanoateNantrodolumNapamideNarcanNardilNarideNatrilixNavaneNavidrexNefazodoneNefazodone hydrochlorideNeo-DiophenN-ethyl MDAN-ethyl-alpha-methyl-3,4(methylendioxy)phenethylamineNeulactilNeur-AmylNexusN-hydroxy MDAN-hydroxy-3,4-methylendioxyamphetamineNicabateNicogelNicoretteNicotineNicotineNicotinellNitrazepamNitrousNitrous oxideNitrous oxideN-methyl-1-(3,4-methylenedioxyphenyl)-2-butanamineNo DozNocturneNolvadexNomapamNon Opioid Analgesics, necNorabolinNorditropinNorephedrineNorethandroloneNormisonNorpseudoephedrineNortriptylineNortriptyline hydrochlorideNose candyNovatrolNoxitemNucosefNurofenNutmegNyal ColdexNyal DecongestantNyQuilNytamelOlanzapineOne comma fourOne four B-D-OOne four beeOpiod Antagonists, necOpioid analgesicOpiumOpium gelOrabol-HOrabolinOrapOrdineOrganic Opiate Analgesics, necOroxineOrthoxicolOsmitrolOtenabantOther Anabolic Agents and Selected Hormones, necOther Antidepressants and Antipsychotics, necOther Drugs of ConcernOther sedatives and hypnotics, necOther Sedatives and Hypnotics, necOther Stimulants and Hallucinogens, necOther Volatile Solvents, necOther Volatile Solvents, necOx bloodOxandroloneOxazepamOxis TurbuhalerOxycodoneOxycodoneOxycodone hydrochlorideOxycodone pectinateOxymesteroneOxymetholoneOxymorphonePain killersPainstop SyrupPaintPaint removerPaint thinnerPalfiumPaliperidonePamaxPanadeinePanadeine FortePanadeine PlusPanadolPanadol sinusPanafenPanalgesicPanamaxPanamax CoPapaveretumParacetamolParacetamolParadexpara-FluorophenylpiperazineParaldehydeParalginParamethoxyamphetamineParamethoxymethamphetaminepara-MethoxyphenylpiperazineParaperazineParnateParoxetineParoxetine hydrochloridePCEPCPPEGPentazocinePentazocine hydrochloridePentobarbitonePentothalPep pillsPeptide hormonesPeptide Hormones, Mimetics and Analogues, necPerchloroethylenePericyazinePerosprionePertofranPethPethidinePethidine hydrochloridePetrolPetroleumPetroleumPeyotepFPPPharma-ColPhenadoxonePhenazocinePhencyclidinePhendimetrazinePhenelzinePhenelzine sulfatePhenerganPhenethylamine analoguesPhenethylamines, necPhenmetrazinePhenobarbitonePhenobarbitone sodiumPhenolphthaleinPhenothiazines, necPhensedylPhenterminePhenylpiperazine analoguesPhenylpropanolaminePhyseptonePiminodinePimozidePiperazines, n.e.cPiperonylpiperazinePipradol hydrochloridePipradrolPlacilPlaster removerPMAPMMApMPPPolyethylene glycolPoppersPoppy strawPotPotassium-sparing diureticsPPAPregnylPrimobolanPrimobolan DepotPrimoteston DepotProbolinProdeine 15ProfasiProladonePromethazinePrometheganProminalPropanePropanePropofolPropyl nitrateProtabolProtaphaneProthiadenProthiazineProvironProzacPseudoephedrinePseudoephedrine hydrochloridePseudoephedrine sulfatePsilocinPsilocinePsilocybinPsilocybin or PsilocinPsilotsinPsychostimulants, necPthalimidopropiophenonePVCPVC cementPyr-TQatQuaaludeQuetiapineQuinalbarbitoneRafenRalozamRapideineRapifenRastinonReceptozoneRed heartsRed speedReeferRemifentanilRemoxiprideRespaxRespolinRimonabantRispaRisperdalRisperdal ConstaRisperdal QuickletRisperidne-GARisperidoneRisp-genrichealthRitalinRivotrilRixadoneRobitussenRockRock candyRocket fuelRohypnolRoidsRomerganRowiesRubber cementRubbing alcoholRushSaizenSalbutamolSalbutamol sulfateSalmeterolSalmeterol xinafoateSanvalSARIScopolamineSecbutobarbitoneSemi-DaonilSemisynthetic Opioid Analgesics, necSennaSeotonin Reuptake Inhibitors, necSerapaxSerenaceSereventSeroquelSerriesSertindoleSertralineSertraline hydrochlorideSerzoneSevofluraneSevoraneShabuSinequanSinutabSkagSkunkSleepersSleeping pillsSmackSnowSNRISnuffSnusSodium oxybateSodium phosphateSolanaceous alkaloidsSolianSolprinSomatropinSonerylSorbitolSpecial KSpeedSpeedballSpiractinSpironlactoneSpot 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butane3-(2-dimethylaminoethyl)-4hydroxyindole3,4,5-trimethoxy-a-methylphenylethylamine3,4,5-trimethoxyphenylethylamine3,4-methylendioxyethamphetamine3,4-methylendioxymethamphetamine3,4-methylendioxy-n,a-dimethylphenylethylamine3,4-methylenedioxyamphetamine3-fluoromethcathinone3-FMC3-methylfentanyl3-Trifluromenthylphenylpiperazine4-Bromo-2,5-dimethoxy-1-benyzlypierazine4-bromo-2,5-dimethoxyamphetamine4-bromo-2,5-dimethoxyphenethylamine4-FPP4-HO-DIPT4-hydroxybutanoic acid4-Hydroxy-di-isopropyl-tryptamine4-methoxy-1-methylphenylethylamine4-methyl-2,5-dimethoxyamphetamine4-MPP5-methoxy-3,4-methylendioxyamphetamine5-methoxy-N, N-dimethytryptaminePreferred method of use(Required)IngestsSmokesInjectsSniffs (powder)Inhales (vapour)OtherFrequency of use(Required)Multiple times per dayEvery day2 to 3 times a weekOnce a week2 to 3 times a monthOnce a monthLess than once a monthIf you have injected drugs, when was the last time?(Required) Last injected three months ago or less Last injected more than three months ago but less than or equal to twelve months ago Last injected more than twelve months ago Never injected Have any other areas impacted your life?(Required) Yes No Areas of impact(Required) Gambling Sexual addictions Violent behaviour, anger, agression Self harm Eating disorders Other Please describe any other areas of impact(Required)Why do you feel that you need to come into the Living Free program?(Required) PREVIOUS TREATMENTHave you ever been admitted to another rehabilitation program?(Required) Yes No Rehab/Program Name(Required) How long ago?(Required)Within the last year1-2 years ago2-5 years ago5+ years agoIf your admission was terminated or left incomplete, please provide detail(Required)What other help or services have you tried to access (e.g. detox, counselling)? Were they helpful? FINANCIALThe payment of debts will need to be organised through our financial counsellor. Please ensure you have all debt information available for the next stage of the intake process.Are you currently receiving a Centrelink benefit/payment?(Required) Yes No Have you ever received a Centrelink benefit/payment?(Required) Yes No Do you have any Centrelink debts?(Required) Yes No Approximately how much do you owe Centrelink?(Required)Do you have any other debts? E.g. Cash Converters, Courts Fines etc...(Required) Yes No Approximately how much do you owe in other debts?(Required) LEGALThis will be discussed at a later date with our assessment team. Do you have any current criminal convictions?(Required) Yes No Do you have any upcoming court matters?(Required) Yes No CONSENTHow did you hear about Teen Challenge SA?(Required) Web Search Radio Word of Mouth Event DASSA Church Other Other(Required) Conditions(Required) I understand the items below:PROCESS FEE AND FINANCES There is a non-refundable processing fee of $500 to be paid once you have been approved for entry. This fee covers set-up and administration, transport, ambulance cover, and the interview process. PROGRAM TERMS - The Living Free program is a 12-month residential program and is Christian-based. - The Living Free program is non-smoking. - The cost of the program is 100% of your eligible Centrelink benefit/payment (or equivalent if ineligible for Centrelink)CommentsThis field is for validation purposes and should be left unchanged.
