To register for either of the MARP programs complete the online assessment form below or download the form in MS Word format, complete it and mail it in to us. You will receive a phone call from us (usually within a week) to conduct a screening to ensure our program meets your needs. Then your name will be placed on a waitlist and you will be required to contact us on a weekly basis to reconfirm your interest and as a show of commitment. A face to face assessment will be conducted ASAP.

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Registration Form

Who have you been referred by?	Self      Worker/Agency
Referrer Name:
Referrer Agency:
Referrer Phone:
Referrer Fax:
Program of interest:	Residential Rehabilitation      Supported Accommodation
Gender:	Male      Female
Date of Birth:
Name:
Address:
Suburb:
Postcode:
Phone (Home):
Phone (Work):
Phone (Mob):
Email:
Marital Status:	Single     Married     Separated     Divorced
(Please tick if applicable) I have a child/children, their age(s) are:
(Please tick if applicable) I will require child care for my child/children
(Please tick if applicable) I have a disability requiring special needs. (List details below):
Language spoken at home:

What is your main substance of choice?:			How long?:
How much are you using?:			Last Used?:

Please list other substances used and how long you used each one for:



Please list prescribed medication below (make sure you include the Name of the Medication, Strength, Daily Dose and Why you are taking it):



Please list prescribed medication over the past 2 years that you are no longer taking:



Please list over the counter medication:



Where and When else have you received treatment for your addiction?
Include counselling, de-tox, doctors, hospitalisations, etc.):



Do you have any other health issues? (Include psychiatric, physical, etc):



*** If you answered 'Yes' to either of the last 2 questions, please complete the
Release of Information Form and post or fax to: MARP 17 Clarke Street, Lilydale 3140. No assessment will be booked until this is received. ***


Please tick if you have ever had a major illness or injury. Please give details below:



Please tick if you have a history of violence when sober/clean. Please give details below:



Please tick if you have any outstanding legal issues. Please give details below:



Please tick if you have any previous convictions. Please give details below:



So that you have some idea what is expected of you whilst in our Residential Rehabilitation Program we have listed the following things which are compulsory whilst you are in 'Croydonbridge':

• To remain abstinent from both alcohol and drugs whilst in the program
• To participate in group program
• To attend meetings for Individual Treatment Planning. This is goal setting and review.
• To have a commitment to work on individual treatment goals.
• To participate in evening communal meal on weeknights.
• To complete rostered duties (Cooking/cleaning)
• To attend meetings of both NA and AA
• To sleep overnight unless prearranged. (Sometimes permitted in your final stage of program)
• To not bring your vehicle to the Residential Rehabilitation Property
• To acquaint yourself with house rules (Supplied on Entry)

If you wish to be placed on the MARP waiting list, make sure this form has been completed and click the 'Register' button (below).