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Residential Program: Online assessment
This questionnaire is the initial assessment for acceptance into the Dreambuilders Transformations drug and alcohol rehabilitation program. All responses will be kept confidential and will be used solely for assessing your acceptance into the Program. Please provide responses to all questions so that we can properly complete the assessment process.
Please contact us if you'd prefer to complete this assessment over the phone.
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CONTACT DETAILS
Name:
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Your answer
Email address and/or phone number:
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Your answer
QUESTIONNAIRE
1. Have you been struggling with challenging or addictive behaviours, for example, drinking, drugs, porn, gambling, eating, sex, or relationship addictions?
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Yes
No
2. What is your drug of choice, or challenging behaviour?
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Your answer
3. Have you thought about stopping or have you tried to stop before?
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Yes
No
4. If yes, how successful were you?
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Type 'N/A' if you haven't tried stopping before.
Your answer
5. Are you currently working?
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Yes
No
6. Are you currently in jail or on bail?
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Yes
No
7. Do you receive Centrelink benefits?
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(Note: if you don't receive benefits but are eligible, you will need to contact Centrelink to apply for an allowance prior to admission)
Yes
No
8. Do you have a Medicare card?
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(If you don't, you''ll need to apply for one prior to admission)
Yes
No
9. Are you physically able to fulfill the work component of the program, e.g., gardening, maintenance, cleaning, odd jobs, and kitchen duties?
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Yes
No
10. This is a faith/spiritual-based program - are you comfortable with this?
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Yes
No
11. Are you willing to participate in the spiritual aspects of the program, e.g., attending devotions, and church on Sundays?
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Yes
No
12. Are there any other comments that you would like to add?
Your answer
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