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Detox – up to 28 days inpatient withdrawal program
Rehab – 12 week residential rehabilitation program
Both Detox and Rehab
Enter mobile or phone number 0414 111 111 or 02 9212 2002
Please enter full address, including State and Postcode
(If you are referring yourself, put ‘myself’)
e.g. FACS, mother, friend (If you are referring yourself, put ‘myself’)
Are you working with Family and Community Services
Are you working with Juvenile Justice
Complete relevant carer details below:
Please provide their first and last names
(This is the number that appears to the left of your name on your Medicare Card)
If yes, please provide a copy of the hospital discharge summary. Failure to provide will delay admittance to the program.
If yes, please provide a copy of the Order. Failure to provide will delay admittance to the program.
Unemployment Benefit (Centrelink)
If yes, please provide a copy of criminal history. Failure to will delay admittance to the program.
If yes, please provide police facts. Failure to provide will delay admittance to the program.
Have you/they received support from a community-based worker of any kind (e.g Juvenile Justice officer, Probation & Parole officer, mental health worker, GP support, counsellor, mentor, social worker or case manager)?*
Please note the 2C Risk Assessment Form needs to be completed by the most relevant support worker and sent to the TCF Intake Coordinator in addition to this online referral form. Failure to do so will slow down the application process.
I confirm that, to the best of my knowledge, all information on this application form is correct
By entering your full name, you have electronically signed this form.