Pindari House Break Free From Addiction

Pindari Resident Application

Please fill out the following Application. Fields marked * are required.

About you
About you
Current living address
Current living address
Emergency contact
Emergency contact
Relationship to you *
Work and income
Work and income
Employment status *
Are you currently on Centrelink / Benefits or Pension? *
Cultural needs
Cultural needs
Do you have any specific cultural needs? *
Living situation
Living situation
Current accommodation *
Living arrangement *
Legal
Legal
Do you have any convictions for sexual offences or arson offences? *
Are you on bail or parole, or do you have any upcoming court hearings? *
How did you hear about the Pindari Program?
How did you hear about the Pindari Program? *
Substance use
Substance use
What are your drug(s) of concern? *
Mental health
Mental health
Do you have a mental health diagnosis? *
Medication
Medication
Are you on any medication? *
Physical health
Physical health
Do you have the physical health capacity to participate in physical work as part of the program? *
Do you have any allergies? *
Do you have HIV or Hepatitis A, B or C? *
Declaration
Declaration

I agree to the following Terms of Application:

I understand that, in evaluating my suitability for the program, Pindari Restoration House management may contact health professionals for advice and/or make contact with my family/next of kin.

I give permission for Pindari Restoration House to obtain relevant information from medical practitioners, other agencies and/or medical health professionals and share this information in order to assess this application and future treatment. This includes, but is not limited to, results of all blood test and urine analysis and investigations, diagnosis of any medical conditions and prescriptions of any medications including any information on My Health Record.

I agree to allow my medical practitioner and/or psychiatrist and/or psychologist to share information with Pindari Restoration House regarding any physical or mental health conditions I may have. I understand that this information will be kept confidential.

I hereby state that the information I have provided in this Application Form is true and correct and that if I have purposely provided false information I will be dismissed from the program even after acceptance.

Your privacy: what you write here goes only to Pindari Ministries' intake staff and is used to assess your application. It is stored encrypted, moved into Pindari's secure client system, and then removed from this website. It is not shared with anyone else except as described in the declaration above. Questions? Call us before filling this in.
Please answer the highlighted question(s) - at least one box needs a tick.