Online Application Form

Personal Details

Surname *

Given Names *

Date of Birth

Are you: *
MaleFemale

Mobile

MIN *

Medicare Number:

Centrelink Reference Number:

Your Contact Person/Next Of Kin *

Relationship

Their Phone:

Postal Address

If Yes, when and for how long?

Have You Recieved Money In The Past 12 Months From Any Of The Following? *
Part-time EmploymentGovernment BenefitFull-Time EmploymentOther income Sources

Legal Matters

How Many Times Have You Been Arrested In The Past 12 Months? *

How Old Were You When You Were Arrested For The First Time?

Are You Currently On Bond, Bail or Other?
YesNo

If Yes, Please Specify

Do You Have Any Outstanding Legal Matters?

Is Drug & Alcohol Rehabilitation A Condition That Has Been Legally Imposed On You?
YesNo

If Yes, Please Specify

Have You Ever Been In Custody? *
YesNo

Are You Currently In Custody?
YesNo

Current Charges *

Past Charges *

Anticipated Date of Court/Discharge

Solicitor's Name

Solicitor's Address

Solicitor's Phone *

Solicitor's Email *

Do You Give Consent For Wayback To Discuss Your Application With Your Solicitor? *
YesNo

Probation & Parole/Welfare Worker/Case Worker Name *

Phone *

Email *

Do You Have A Residence To Return To When Discharged From Wayback?
YesNo

Education/Employment/Training

What Is The Highest Year Of School You Have Completed?

What's The Highest Education Level You Achieved?
No Education Beyond Secondary SchoolSome TAFE But Not CompletedCompleted TAFE ProgramSome University But Not CompletedCompleted University

What Is The Longest Period You Have Remained In A Job?

Children

Do you have children? *
YesNo

If Yes, How Many Children Do You Have? And How Often Do You See Them?

Are You Responsible For Taking Care Of Any Children Under The Age Of 18 Years Of Age?
YesNo

If Yes, How Many Children And What Age?

Are Your Children In The Care Of FACS?
YesNo

If Yes, How Many & How Often Do You See Them?

Are You Subject To Any FACS Order? If Yes, Please Give Details

Addiction History

What Is Your Drug/s Of Choice? *

Are You On Any Methadone / Buprenorphine Program?
MethadoneBuprenorphineNone

Please Complete The Following Details About Your Drug Use History:

Drug

Frequency of Use

Average Quantity

Age When First Used

Last Use

Amount Last Used

How Many Days Did You Use In The Last Month

Method

Have You Ever Been Hospitalised As A Result Of An Injury or Overdose Whilst Intoxicated? If Yes, Please Give Details.

In The Past 30 Days, How Often Did You Gamble?
Not At AllOnce Or Twice A WeekThree Or More Times A Week

If You Did Gamble, What Was The Main Form Of Gambling You Did?

Health History

Have You Taken Any Prescription or 'Over The Counter' Medications In The Past Week?
YesNo

If Yes, Please Explain What Type Of Medication, Reason And What Dosage?

Have You Ever Required Assistance From A Psychiatric Practitioner Or Psychological Service For The Following:
SuicideSelf HarmDrug Induced PsychosisOther

If You Answered Yes To Self Harm And/Or Suicide, Please Provide Details (eg Date, Method Of Harm, What Happened After. etc):

Have You Ever Been Diagnosed With Any Of The Following Conditions:

Please Give Details For All Diagnoses Including Doctor, Dates, Treatments Sought, Impact On Lifestyle & Ability To Function:

Miscellaneous Matters

Tell Us About Your Detox / Rehab History?

Are There Any Personal, Legal Or Medical Issues That Need Attention Whilst At Wayback?

What Are You Hoping To Gain From The Wayback Program? *

***PLEASE ATTACH ANY RELEVANT REPORTS / DISCHARGE SUMMARIES/ FACTS / CRIMINAL HISTORY***

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