Name and address of next of kin
Any legal actions outstanding
Details of last conviction/sentence
Details of previous convictions
Details of probation orders
Probation Officer name, address and tel. no.
Have you been in rehabilitation before?
Which project are you applying for?
What do you hope to achieve during your stay?
Do you consider yourself to have a problem with:
Please specify your mental ill health here
Are you presently taking medication?
If yes, what do you take?
Have you ever had or are you having any psychiatric treatment?
If yes, where, when and what for?
Name and address of referral agency ?
If self-referral / self-funding, please state.
Have you been formally assessed as needing residential rehabilitation?
By whom - name and address
Has funding been agreed?
Funding agency details - name, address and tel. no.