New Customer Registration Form

The Helping Hand (THH) Referral Form

Please complete this form with as much detail as possible to assist us in assessing the suitability of your client for our 6-month residential rehabilitation program. We will review and respond back to you within 3 working days. Thank you.
SECTION 1. ELIGIBILITY CRITERIA*

The male applicant is 21 years old and above.The applicant does not have any outstanding warrant of arrest / unaccounted criminal offence. Check Outstanding Warrant to Arrest Enquiry System (OWAES): https://eservices1.police.gov.sg/phub/eservices/landingpage/outstanding-warrant-to-arrest-enquiryThe applicant is willing and motivated to engage in THH’s 6-month residential abstinence-based rehabilitation program.The applicant has completed / is expected to complete at least 2 weeks of inpatient detoxification and rehabilitation treatment.The applicant is free from serious infection diseases that may be easily transmitted in a communal setting.The applicant is not experiencing serious psychotic disorders and/or serious behavioral problems that require close individual supervision or nursing care.The applicant is not experiencing suicidal ideation and does not have risks of suicide.The applicant agrees to engage in The Helping Hand’s Christian-based program.The applicant is reasonably fit and able to engage in work initiatives (e.g. cleaning, removals, maintenance, kitchen helper, etc.)
If the applicant is unable to meet any of the above criteria, please provide the reason below to support the referral application. Referrals that do not meet these criteria may be considered on a case-by-case basis following further review by THH Management Team.
SECTION 2: REFERRING AGENCY DETAILS
Name of Referrer: Full Name*
Designation: Appointment*
Name of Referring Organisation:   Organisation Name*
Contact Number     Country Code*   Phone Number*
Date of Referral   Date*
SECTION 3: CLIENT DETAILS
Full Name (as per NRIC): Name *
Age:   Age*
Residential /Last Known Address:   Address including postal code*
Mobile Number:         Country Code*   Phone Number*
Religion:   If Any *
Marital Status:   Married/Divorced/Single*
SECTION 4: CLIENT BACKGROUND INFORMATION
Type and History of Substance Use:*
Previous Criminal Record / Convictions (if any):
Previous Employment History:*
Current Treatment / Support Services (if any):
SECTION 5: CLIENT HEALTH INFORMATION
Mental Health Conditions (if any）:
Physical Health Conditions (if any):
Current Prescribed Medication (if any):
DECLARATION:

I confirm that the above information is accurate to the best of my knowledge and that the client has consented to provide this information and submit this referral application.
Completed by Client/ Referrer:*

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The Helping Hand (THH) Referral Form