Committed to helping people with addictions find a way back

  • Call Us

    +61 2 9633 4800

  • Email Us

    reception@wayback.org.au

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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  • Step 5
  • Step 6
  • Step 7

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