Watershed drug & alcohol recovery & education Centre provides a residential (live in) Detox & rehab program as well as a non residential program for those who have commitments. Our holistic Bio-Psycho-Social approach to drug addiction ensures all clients receive the best opportunity to recover.


RESIDENTIAL SERVICES REQUIRED (select below)
Withdrawal Management 5 to 10 days	yes no	Residential Rehabilitation 28 days	yes no
Aftercare Program 9 months	yes no	Whole Progam	yes no


PREVIOUS TREATMENT (select below)
Detox &/ or Rehabilitation History	yes no	Where:	When?:

Pharmacotherapy / Counselling /Outreach Service?


BACKGROUND (select below)
Aboriginal:	yes no	TS Islander :	yes no	AB/TS Islander:	yes no

County of Birth :

Interpreter Required :

Language spoken at home? english etc:

Usual Occupation:

Full-time, part-time or unemployed :

Do you receive Centrelink Benefits ? if so what type:

Marital Status:

Do you have children?	yes no	Are they living at home?	yes no
Usual Accomodation? Rent, own, share, board:		Have you lived there for 3 months or more?	yes no

SPECIAL NEEDS

Childcare / Literacy / Cultural Dietary

DRUG USE HISTORY (Current Drug Use)

1: Drug
Frequency
Quantity
Method

Prescribed?

yes
no

Concern?

yes
no

Duration
Last Used


2: Drug
Frequency
Quantity
Method

Prescribed?

yes
no

Concern?

yes
no

Duration
Last Used


3: Drug
Frequency
Quantity
Method

Prescribed?

yes 58
no 58

Concern?

yes 59
no 59

Duration
Last Used

Injecting Drug Use: (please state)

Last 3 mths - 3-12mths - 12+mths - Never

Presenting Drug Problem:
Other Problem:

OVERDOSE HISTORY

Have you ever overdosed ?

yes
no

Were you hospitalised ?

yes
no

SUICIDE SELF HARM

Have you ever attempted suicide?

yes
no

Were you hospitalised ?

yes
no

Have you ever self harmed?

yes
no

Were you hospitalised ?

yes
no

If so.. how many times self harmed?

Were you hospitalised ?

yes
no

PSYCHIATRIC HISTORY

Do you have a mental illness? yes no If yes.. please state

Have you formally been diagnosed with a mental illness? yes no If yes.. please state diagnosis

Are you currently in treatment ?

yes no

If yes.. current medication & doses

MEDICAL HISTORY

Do you have a history of severe withdrawal symptoms?

yes no

Fits, seizures, anxiety, panic attacks etc. please state.

PREGNANCY

Yes, No or Unsure ?

Confirmed?

yes
no

Any current medical conditions?

yes no

Asthma, liver problems, physical problems, vision concerns, epilepsy, diabetes etc. please state.

Medication & Dosage:

Do you have any allergies? yes no If yes.. please state treatment

Any surgery in the last 6 months? yes no If yes.. please state

LEGAL HISTORY

Do you have any curreny legal issues?

yes
no

Up coming court cases?

yes
no

Have you ever been in jail? yes no If yes.. how long?

For what offence:

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