Initial Enquiry Form
Given Name
*
Middle Name(s)
Surname
*
Telephone Number
*
-
Area Code
Phone Number
Email Address
example@example.com
*
I consent to receiving correspondence and appointment reminders via email or SMS
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Address Line 1
*
Address Line 2
Suburb
*
Postcode
State / Territory
*
Please Select
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australian
Tasmanian
Victorian
Western Australia
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Gender
*
Please Select
Male
Female
Non-binary / Other
Indigenous Status
*
Please Select
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander origin
Neither Aboriginal nor Torres Strait Islander origin
Unknown / Decline to answer
Which Indigenous culture(s) do you identify with (if applicable)?
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Primary drug of concern
*
Other drug(s) of concern
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Do you have a current mental health diagnosis?
*
Yes
No
If yes, please provide details:
Are you undergoing any treatment for your mental health diagnosis (if applicable)?
Yes
No
Do you have any current or regular thoughts about suicide?
Yes
No
Have you attempted suicide in the past eight (8) weeks?
Yes
No
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Do you have any outstanding legal matters?
*
Yes
No
If yes, please provide details:
Do you have a history of violent crimes, including domestic violence orders (DVOs)?
*
Yes
No
Do you have a history of any sex offences?
*
Yes
No
Please provide details of relevant criminal history:
*
By checking, I confirm that I am the client and that I am not submitting this enquiry on behalf of another person.
*
By checking, I agree to be contacted by Sunrise Way in relation to this initial enquiry.
Please verify that you are human
*
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