DESTINY HAVEN: Online Assessment Application Form

ASSESSMENT APPLICATION FORM

INTRODUCTION
CONGRATULATIONS!

You've made the first step in seeking the help you need for recovery.

Here, you will complete a comprehensive assessment by providing us with details about your life, living circumstances, and the difficulties you face. This will help us evaluate your application and decide whether Destiny Haven's community recovery program may suit your needs.

You will need the following in order to complete this application form:
- Centrelink number
- Medicare number
- Details of your previous counsellor/psychologist
- Details of any prescribed medications, including dosages
- A witness to co-sign this assessment form
Please note that this form is comprehensive, so we kindly request that you use a computer to enter your details. Avoid using mobile or tablet devices.

We recommend that you allocate approximately 30 to 45 minutes to complete this application form.

ASSESSMENT APPLICATION FORM

PART 1 OF 5: BASIC INFORMATION
Name*

Given NamesLast NamePreferred Names
Mobile Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Date of Birth*

DayMonthYear
Date
Marital Status
Are you of Aboriginal or Torres Strait origin?
SPOUSE’S DETAILS
Name of Spouse

First NameLast Name
Mobile Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Home Phone Number
Please enter a valid phone number.
NEXT OF KIN DETAILS
Please note that it is policy that your next of kin will be notified on your exit from the program or in the case of misadventure.
Do you agree to this procedure?*
Name of Next of Kin*

First NameLast Name
Mobile Phone Number*
Please enter a valid phone number.
Relationship*
Office Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
CHILDREN
Do you have any children?
Names and ages of children
Name of Carer

First NameLast Name
Mobile Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Home Phone Number
Please enter a valid phone number.
BENEFIT DETAILS
Type of benefit *
Amount per fortnight*
Centrelink Ref. # *
Date of next payment*

DayMonthYear
Date
How did you hear about us?

ASSESSMENT APPLICATION FORM

PART 2 OF 5: QUESTIONNAIRE
2.1 LIFE CONTROLLING ISSUES
Do you use drugs?
If yes, what do you use and how often?
Do you drink alcohol in excess?
If yes, what do you use and how often?
How many years have you been drug or alcohol dependent?
Do you use prescription medications?
If yes, what medications do you use and how much?
Do you or have you ever had an eating disorder?
If yes, please explain.
Do you or have you ever self-harmed?
If yes, please explain.
Have you ever attempted self-harm with the intent to end your life?
If yes, please explain.
What other issues do you have that you need help with?
What other areas would you like to address while at Destiny Haven?
2.2 EMPLOYMENT HISTORY
What type of work have you done?
Do you currently have a job?
If yes, where do you work?
Do you currently have a valid driver’s license?
Have you ever been in jail or been convicted of a crime or offence?
If yes, please provide details
2.3 FINANCES
Are you in debt?
If yes, please provide details as to whom the debt is owed, and how much you owe.
2.4 LEGAL MATTERS
Do you have to appear in court in the near future?
If yes, please provide details of your case.
2.5 OTHER RELEVANT INFORMATION
Do you agree to participate in the daily work program which is a requirement of each client?
Group therapy and education is part of our Training Centre Program. Do you agree to participate fully in this aspect of your recovery?
What is your religion?
Our programs are Christian based and formulated from a Christian worldview. Will you agree to take part in these and complete all homework as required?
Attending Church is part of the program, and attendance is compulsory. Are you willing to participate in this as part of the program?
Destiny Haven is a smoke free program. Do you agree to abide by this rule, knowing that smoking (even on days or weekends out) will incur immediate discharge?
Random drug testing is part of our program and clients may be asked to undertake these. Are you willing to undergo this as requested?
Extreme body piercings are not allowed in our program. Do you agree to remove extreme piercings if requested?
Are you willing to follow all guidelines, and directives given by Destiny Haven staff?
Destiny Haven’s rules have been made for the good of every person in our community. Are you willing to abide by the program rules?
Having read the Destiny Haven rules (Appendix A) and the contract of admission (Appendix B) do you agree to abide by the rules set down for your involvement in the program?
Please download and retain a copy of the following documents.
Appendix A - PROGRAM RULES
Appendix B - CONTRACT OF ADMISSION
I declare that all answers and information I have given are true and correct, and I understand that if found to be otherwise I may be discharged from the program and facility.

Clear
Date

DayMonthYear
Date

ASSESSMENT APPLICATION FORM

PART 3 OF 5: FAMILY AND SIGNIFICANT OTHERS QUESTIONNAIRE
The purpose of this questionnaire is to try and establish the client’s relationship to “significant” other people in their life. Unhealthy relationships between the client and significant others may be a contributing factor to relapse. By identifying the nature of relationships between significant others and the client “the extent to which this co-dependency has impaired the normal development and functioning of each individual” can be determined.
3.1 GENERAL QUESTIONS
Are you married or living with someone?

NoMarriedDe facto
How long has this relationship existed?
How many times have you been married?
How many times have you “lived” with someone?
Do you have a series of short-lived relationships or long-term relationships?

Short-lived relationshipsLong-lived relationships
Have you recently finished a relationship?
How long ago?
What is the quality of your relationship with the following members of your family?

(e.g. is it hostile, neutral, supportive, nurturing, close, loving, alienated?)
Mother (natural, foster, step)
Father (natural, foster, step)
Siblings (natural, foster, step)
Other family figures (Grandparents, aunts, uncles, godparents)
Spouse
Children
What is your position in the family hierarchy? (i.e. first/second/last born/only child)
Were you considered special by either parent?
By which parent and in what ways were you considered special?
Do you have a history of either parent being away a lot as a result of work, illness, etc.?
Can you explain in more detail what this meant for you personally growing up?
3.2 ADVERSE FAMILY CONDITIONS
Is there a history of any of the following conditions occurring in your family that you are aware of?

Go back 3-4 generations if you can and state the family member that the condition
applies to.
1. Drug Abuse
2. Alcoholism
3. Emotional or physical violence
4. Incest or other unusual sexual behavior, (e.g., pedophilia)
5. Suicide or attempted suicide?
6. Mental illness (including agoraphobia, anorexia, etc.)
7. Compulsive gambling
8. Compulsive promiscuity
9. Criminal behaviors
10. Compulsive television viewing
11. Workaholism
12. Excessive relocation/separation from parents
13. Long term illness in the family (physical or psychiatric)
Describe your perception of these problems.
3.3 FAMILY SITUATIONS
Explain the parenting situations in your upbringing. That is, was your family upbringing in a monogamous, heterosexual, nuclear family, or was there a variation from this, and in what ways did the variation affect you?
3.4 SEPARATION
Have you lost someone close to you through any of the following, and who?
1. Death
2. Murder
3. Suicide
4. Divorce
5. Separation
6. Incarceration
As a child were you ever separated from your family due to
Illness
Long periods of hospitalization
Institutionalization (e.g. boarding)
3.5 SOCIABILITY
Have you ever belonged to any social or institutional groups?
Church groups
Community groups
Political groups
Street gangs
Social clubs
Sports groups/clubs
Therapy groups
NA / AA
What is your general attitude towards group affiliations?
Do you prefer to spend most of your free time alone, with one person, or in a group?
Do you have any hobbies? What are they?
Are there any other skills, activities or hobbies you would like to develop in our program, such as sewing, cooking or gardening?
What are some of the areas that you think you will most struggle with in entering a residential program?

ASSESSMENT APPLICATION FORM

PART 4 OF 5: AUTHORITY
4.1 CENTRELINK
I,   First Name*   Last Name*   of   Street Address*   Address Line 2*   City*   State*   Post code*   do hereby give permission for any information concerning my claim for Centrelink to be passed on to the Managers of Destiny Haven. I also give permission for the Destiny Haven Managers to give information in relation to this claim to Centrelink should I be accepted into the program.

Signed: Signature*
Witnessed:  Signature*
Date:   Date*
4.2 PERSONAL
I,     First Name Last name*          do hereby authorize the Managers of Destiny Haven to release information regarding myself to the following: *

Information to be withheld

Please do not discuss any information regarding myself with the following:     *

Signed:   Signature*

Witnessed:   Signature*

Date:      Date*

ASSESSMENT APPLICATION FORM

PART 5 OF 5: MEDICAL INFORMATION
PRIVATE AND CONFIDENTIAL
You must undertake a full blood test within two weeks before being admitted into the Destiny Haven program. The written results must be brought with you on the day of admission. Do you agree to this?*
You are required to bring a doctor’s clearance, declaring your ability to participate in physical activities including fitness training and gardening. Do you agree to this?*
Please take note that it is your responsibility to have your teeth checked prior to being admitted to the program. Any routine visit to a dentist will not be permitted within the first three months of commencement of our program. Only emergency dental treatment will be sought within the first three months. Do you agree to this?*
5.1 MEDICAL DETAILS
Medicare number*
CRN number*
Doctor's name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Do you suffer from any of the following conditions?
Asthma
Diabetes
Epilepsy
Heart problems
High blood pressure
Phobias
Allergies
Do you have active HIV, Hepatitis B or Hepatitis C?*
Have you been tested recently?
If yes, please give details.
Are you aware that you may be required to have further blood tests during the program?*
Are you currently taking any medication?*
If so, what medication and how long have you been taking it?
Have you ever been addicted to medication?*
If yes, please give details.
Do you smoke cigarettes?*
If yes, how many per day?
Do you have any illness at the present time?*
If yes, please give details.
Please note details of any other medical problems that you have.
5.2 HISTORY
Have you ever been to a rehabilitation, recovery or residential program before?
If yes, when, where and how long did you stay?
Have you had contact with the mental health system?
If yes, please give details.
Have you been admitted to a mental health facility?
How many times have you been admitted voluntarily?
How many times have you been admitted involuntarily?
When was your most recent admittance to a mental health facility and what was the reason for your admittance?
Have you seen a counsellor or psychologist before?
If yes, please list his/her details:
Counsellor or Psychologist's name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
For how long did you see this psychologist?
Months
How did seeing this psychologist help?
5.3 OTHER HEALTH INFORMATION
Do you have any special considerations shown below?

(If you do not list any food exclusions, you will be expected to eat whatever is provided).
Dietary
If yes, please give details.
Spiritual
If yes, please give details.
Emotional
If yes, please give details.
Physiological
If yes, please give details.
Behavioural Therapy
If yes, please give details.
Have you ever experienced any of the below?
Depression
If yes, please give details.
Mood swings
If yes, please give details.
Violent outbursts
If yes, please give details.
Anxiety attacks
If yes, please give details.
Panic attacks
If yes, please give details.
Paranoia
If yes, please give details.
Hallucinations
If yes, please give details.
Drug Psychosis
If yes, please give details.
Liver damage
If yes, please give details.
Kidney damage
If yes, please give details.
Stomach ulcers
If yes, please give details.
Anorexia
If yes, please give details.
Bulimia or other
If yes, please give details.
Do you have an addiction?
If yes, please give details.
Are you pregnant?
If yes, please give details.
5.4 CLIENT MEDICAL CONTRACT
I First Name* Last Name* agree to the following terms and understand that if I breach any part of this contract I will be discharged from the Destiny Haven program.
Diagnosed Illnesses
Prescribed Medication
I understand that:
- My medication will be held in the office and dispensed by Staff of Destiny Haven.
- I must ensure that I have a repeat prescription of my medication at the time of arrival.
- Any alterations to the above must first be approved by Destiny Haven’s consulting Doctor, in consultation with Destiny Haven’s Management.
Signature*

Clear
Date

DayMonthYear
Date
5.5 AUTHORITY MEDICAL
CONSENT TO OBTAIN INFORMATION
I, First Name* Last Name* of Street Address* Address Line 2* City* State* Post code* hereby give permission for the Managers of Destiny Haven Life Development Training Centre to obtain relevant information from medical practitioners, other agencies and/or medical health professionals specifically relevant to my management and treatment while a resident of Destiny Haven Life Development Training Centre.
CONSENT TO RELEASE INFORMATION
I, First Name* Last Name* hereby agree to undertake a full blood test prior to arriving at Destiny Haven and to bring the results with me on the date of my arrival into the program.
I agree to allow my medical practitioner to speak to the Management of Destiny Haven regarding any physical or mental problems I may have. I also agree to make arrangements to have my medical records sent to the local medical practitioner on my arrival at Destiny Haven.
Consent to obtain information*

Clear
Consent to release information*

Clear
Date

DayMonthYear
Date
Witnessed by*

Clear
Date

DayMonthYear
Date
I HAVE READ THE PROGRAM RULES AS LISTED IN APPENDIX A AND APPENDIX B AND AGREE TO ABIDE BY THEM AS STATED.*

Clear
Date

DayMonthYear
Date
Should be Empty:

ASSESSMENT APPLICATION FORM

ASSESSMENT APPLICATION FORM

SPOUSE’S DETAILS

NEXT OF KIN DETAILS

CHILDREN

BENEFIT DETAILS

ASSESSMENT APPLICATION FORM

2.1 LIFE CONTROLLING ISSUES

2.2 EMPLOYMENT HISTORY

2.3 FINANCES

2.4 LEGAL MATTERS

2.5 OTHER RELEVANT INFORMATION

ASSESSMENT APPLICATION FORM

3.1 GENERAL QUESTIONS

3.2 ADVERSE FAMILY CONDITIONS

3.3 FAMILY SITUATIONS

3.4 SEPARATION

3.5 SOCIABILITY

ASSESSMENT APPLICATION FORM

4.1 CENTRELINK

4.2 PERSONAL

ASSESSMENT APPLICATION FORM

5.1 MEDICAL DETAILS

5.2 HISTORY

5.3 OTHER HEALTH INFORMATION

5.4 CLIENT MEDICAL CONTRACT

5.5 AUTHORITY MEDICAL