Residential Program: Online assessment
This questionnaire is the initial assessment for acceptance into the Dreambuilders Transformations drug and alcohol rehabilitation program. All responses will be kept confidential and will be used solely for assessing your acceptance into the Program. Please provide responses to all questions so that we can properly complete the assessment process.

Please contact us if you'd prefer to complete this assessment over the phone.
CONTACT DETAILS
Name: *
Email address and/or phone number: *
QUESTIONNAIRE
1. Have you been struggling with challenging or addictive behaviours, for example, drinking, drugs, porn, gambling, eating, sex, or relationship addictions? *
2. What is your drug of choice, or challenging behaviour? *
3. Have you thought about stopping or have you tried to stop before? *
4. If yes, how successful were you? *
Type 'N/A' if you haven't tried stopping before.
5. Are you currently working? *
6. Are you currently in jail or on bail? *
7. Do you receive Centrelink benefits? *
(Note: if you don't receive benefits but are eligible, you will need to contact Centrelink to apply for an allowance prior to admission)
8. Do you have a Medicare card? *
(If you don't, you''ll need to apply for one prior to admission)
9. Are you physically able to fulfill the work component of the program, e.g., gardening, maintenance, cleaning, odd jobs, and kitchen duties? *
10. This is a faith/spiritual-based program - are you comfortable with this? *
11. Are you willing to participate in the spiritual aspects of the program, e.g., attending devotions, and church on Sundays? *
12. Are there any other comments that you would like to add?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy