Gulgihwen Program Application Form

Namatjira Haven respects your privacy. Any information you provide here will remain confidential within our service. By submitting this application you acknowledge that you have consented to us collecting your personal information. If we need to share your information with anyone else in order to assess you further, we will seek your consent in follow up contacts.

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Do you identify as Aboriginal and/or Torres Strait Islander?
Tick this box to confirm you are a man over 18 years of age
Have you been to Namatjira Haven Before?
If yes what year?
What is your usual address? If you do not have a fixed address, just put the town, state and postcode
Street
Town
State
Postcode
Do you have anywhere to live at present?
Your contact number
Your email address
What substances (drugs and alcohol) are a concern for you? Briefly tell us what substances are a problem, how often you use them (e.g. everyday, a few times a week, a few times a month), how you take them (e.g. eat/drink, inject, smoke, snort, etc) and when you last used them
Do you have legal matters at this time, including prison, AVO's, court hearings, bail or parole?
If yes, briefly tell us what they are
Are you being referred to us by someone else?
If yes, briefly tell us who they are and their contact details
Thank you for your application. Please tick this box to confirm you have read our eligibility guidelines
It is up to you to follow up your application. Please tick this box to understand you will contact us within 2 working days to follow up your application