Giving Back Australia

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Get Off Drugs Request Form

Personal Information

All Fields Marked With A Red Asterisk (*) Are Required For The Form To Be Submitted

Apply For Assistance Getting Off Drugs

*First Name

*Surname

*Email:

*Phone:

Unit Number if Applicable

*Street Address and Suburb

*State

Emergency Contact Name

Contact Number

Email:

Street Address:

*Applicants Drug History Prescription / Medical Drug Use

*Have The Prescription Drugs Been Prescribed For You?

*Have You Abused Your Prescription Drugs?

*Do You Use More Than One Drug At A Time?

*What Drugs Do You Use?(List One Per Line)

*How Long Have You Been Using These Drugs?

*Have You Been, Or Are You, Able To Go Any Length Of Time Without Using These Drugs?

*What Kind Of Time-Frame Were You Able To Stop Using The Drugs For?

*What Is The Longest Period You Managed To Last Without Taking The Drugs?

*Are You Able To Stop Using Drugs Whenever You Want To?

*Are You Still Using These Drugs?

*Have You Ever Tried To Quit Permanently?

If You Answered Yes, Please tell us about the method used for example( I spent time in rehab)

*Do You Ever Feel Guilt Over Your Drug Use?

*Does Your Family Ever Complain About Your Drug Usage?

*Has Your Drug Use Created Problems Between You And Your Family?

*Have You Lost Friends Because Of Your Drug Use?

*Have You Ever Neglected Your Friends Or Family Because Of Your Drug Use?

*Do You Find It Difficult To Maintain Employment As A Result Of Your Drug Use?

*Are You Currently Employed?

*Have You Had Trouble At Work Due To Your Drug Usage?

*Have You Ever Lost A Job As A Result Of Your Drug Use?

*Are You Currently Experiencing, Or Have You Ever Experienced Financial Instability As A Result Of Your Drug Usage?

*Have You Been Involved In Physical Altercations As A Direct Consequence Of Your Drug Usage?

*Other Than Buying Your Drugs, Have You Ever Engaged In Any Form Of Illegal Activity To Support Your Drug Habit Or As A Result Of Drugs?

If You Answered Yes, Please Give us more information example. ( I have been in custody due to drugs)

*Have You Ever Been Arrested As A Consequence Of Drug Use?

*Do You Ever Experience Withdrawal Symptoms?

If You answered Yes Please Describe The Withdrawal Symptoms:

*Have You Ever Had Medical Problems Due To Your Drug Use?

*Do You Have Hallucinations?

*When You Have Hallucinations, Are You Using Drugs At The Time?

*Have You Seen A Mental Health Professional Regarding Your Hallucinations?

*Have You Ever Sought Out Help To Stop Your Drug Use?

*Have You Ever Sought Help From A Medical Professional To Stop Your Drug Use?

*Have You Ever Entered Into A Treatment Program Specifically Tailored For Drug Users?

*Have You Ever Been Diagnosed As Having Any Psychological Illnesses Or Psychological Disorders?

If You Answered Yes, Please Give Details Example,( I Have Diagnosed schizophrenia )

*Are You Taking Medications For The Treatment Of This/These Condition(s)?

If You Answered Yes, Please Give Us Details.

Can You Provide Any More Information That Will Aid The Development Of Your Treatment Plan?

*I Hereby Declare That The Above Information Is True And Correct To The Best Of My Knowledge. I Have Also Viewed And Understood Giving Back Australia's Privacy Policy And Am Voluntarily Supplying My Personal Information In Order To Receive Assistance.

*Acknowledged By:

Thank You For Taking The Time To Complete The Application Form. We Appreciate Your Time And Co-Operation.

Please Note: All Supporting Documents Must Be Uploaded Using The File Upload Button Below, In Order For Us To Process Your Application.

Apply For Assistance Getting Off Drugs

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