Online Application Form

The following information will ask you for relevant background material that will assist Wayback in providing you with the most appropriate rehabilitation treatment services. This information will remain confidential with only the clinical staff at Wayback or others with legal entitlement having access to it.

Wayback Online
Application Form

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    Personal Details









    MaleFemale







    Postal Address



    AboriginalTSIBothNeither

    AboriginalTSIBothNeither

    Never Been MarriedDeFacto RelationshipMarriedSeparated/DivorcedWidowedSingle


    YesNo

    YesNo




    Part-time EmploymentGovernment BenefitFull-Time EmploymentOther income Sources



    Legal Matters





    YesNo




    YesNo



    YesNo


    YesNo




    Solicitor's Name

    Solicitor's Address





    YesNo





    YesNo



    Education/Employment/Training




    No Education Beyond Secondary SchoolSome TAFE But Not CompletedCompleted TAFE ProgramSome University But Not CompletedCompleted University




    Children



    YesNo



    YesNo



    YesNo





    Addiction History




    MethadoneBuprenorphineNone











    Not At AllOnce Or Twice A WeekThree Or More Times A Week




    Health History



    YesNo



    SuicideSelf HarmDrug Induced PsychosisOther






    Miscellaneous Matters