Application Form

We regret we are not a crisis service and we can not help with urgent matters.

Crisis Information

Apply to the Program

1Personal Details

2Current Circumstances

3Consent

Personal Details

Name(Required)

First Last

Please tick the box to confirm you are male and are over 18 years old(Required)

I confirm I am a male and I am over 18 years old

Indigenous Status (select one option only)(Required)

I am Aboriginal

I am Torres Strait Islander

I am both Aboriginal and Torres Strait Islander

I am neither Aboriginal or Torres Strait Islander

If you identify as Aboriginal, what nation do identify as coming from?

Your date of birth (use the date picker or enter it in the dd/mm/yyyy format)(Required)

DD slash MM slash YYYY

Age

Are you in a current relationship?

Yes

Employment / Income Status

What is your current employment/income status?

Employed Full Time

Employed P/T

Pensioner

Student

Unemployed

Other

Documentation

I have a current Medicare Card

I have current Keycard

I have a current MyGov Account

I receive a Centerlink Payment

If you do not have these you will be asked to obtain these prior to entry. Please discuss with the intake officer

Contact Details

What is your email address (if you have one)?

What is your contact phone number (if you have one)?

What are your current living circumstances?

Homeless / No Fixed Address

Renting

Boarding

Own your Place

Staying with Family/Friends

Other

If you are homeless or have no fixed address just tell us the city or town that you normally live in

Town or Suburb State

What is your usual address? Please tell us the number, street, city or town, state and postcode.

Street Address Town or Suburb State Post Code

Current Circumstances

Have you ever been previously admitted to Namatjira Haven?

Yes

I'm not sure

If yes, what year did you stay here?

What substances (drugs and alcohol) are a concern for you?(Required)

Briefly tell us what substances are a problem, how often you use them (e.g. everyday, a few times a week, a few times a month), how much you take and how you take them (e.g. eat/drink, inject, smoke, snort, etc). When did you last use these?

Briefly describe what you are hoping to achieve coming to Namatjira Haven

Do you have Physical or Mental Health issues or a disability?(Required)

Yes

Please briefly tell us about your health issues or disability and any prescribed medications that you are taking.

Do you think you need help to detox before entry?(Required)

Yes

Not Sure

All persons accepted must be Drug & Alcohol free on admission. If your application is accepted, this requirement, and options for a withdrawal management program (e.g. Detox), will be discussed with you during assessment.

What, if any, legal matters do you have at this time, including prison, AVOs/ADVOs, court hearings, family court matters, bail, probation or parole?(Required)

Please ensure you have read the eligibility criteria regarding applying while you have legal matters.

Are you being supported by a professional such as a Health or Community Worker, Solicitor, Corrections Officer?

Yes

Details of the person supporting you.

Name person supporting you

First Last

Organisation of person supporting you

Phone number of person supporting you

Email of person supporting you

Consent

I have read the eligibility criteria and guidelines.(Required)

I confirm that I have read the eligibility criteria and guidelines. To the best of my knowledge I believe I meet the criteria.

Review Eligibility Criteria here if you are not sure.Opens in a new tab

I understand it is up to me to follow up my application(Required)

I understand it is up to me to follow up my application by ringing the intake officer on phone 02 6628 1098 no earlier than 2 working days after I submit this application. The Intake Officer is only available between 10 am and 3 pm Monday to Thursday.

To your knowledge are you related to, or do you have a relationship with, any staff or Board member or current resident of Namatjira Haven?(Required)

Yes

Not Sure

If yes, who is the staff or Board member or current resident and what is the nature of that relationship?(Required)

Name

This field is for validation purposes and should be left unchanged.

Apply to the Program

1Personal Details

2Current Circumstances

3Consent

Personal Details

Name(Required)

First Last

Please tick the box to confirm you are male and are over 18 years old(Required)

I confirm I am a male and I am over 18 years old

Indigenous Status (select one option only)(Required)

I am Aboriginal

I am Torres Strait Islander

I am both Aboriginal and Torres Strait Islander

I am neither Aboriginal or Torres Strait Islander

If you identify as Aboriginal, what nation do identify as coming from?

Your date of birth (use the date picker or enter it in the dd/mm/yyyy format)(Required)

DD slash MM slash YYYY

Age

Are you in a current relationship?

Yes

Employment / Income Status

What is your current employment/income status?

Employed Full Time

Employed P/T

Pensioner

Student

Unemployed

Other

Documentation

I have a current Medicare Card

I have current Keycard

I have a current MyGov Account

I receive a Centerlink Payment

If you do not have these you will be asked to obtain these prior to entry. Please discuss with the intake officer

Contact Details

What is your email address (if you have one)?

What is your contact phone number (if you have one)?

What are your current living circumstances?

Homeless / No Fixed Address

Renting

Boarding

Own your Place

Staying with Family/Friends

Other

If you are homeless or have no fixed address just tell us the city or town that you normally live in

Town or Suburb State

What is your usual address? Please tell us the number, street, city or town, state and postcode.

Street Address Town or Suburb State Post Code

Current Circumstances

Have you ever been previously admitted to Namatjira Haven?

Yes

I'm not sure

If yes, what year did you stay here?

What substances (drugs and alcohol) are a concern for you?(Required)

Briefly describe what you are hoping to achieve coming to Namatjira Haven

Do you have Physical or Mental Health issues or a disability?(Required)

Yes

Please briefly tell us about your health issues or disability and any prescribed medications that you are taking.

Do you think you need help to detox before entry?(Required)

Yes

Not Sure

What, if any, legal matters do you have at this time, including prison, AVOs/ADVOs, court hearings, family court matters, bail, probation or parole?(Required)

Please ensure you have read the eligibility criteria regarding applying while you have legal matters.

Are you being supported by a professional such as a Health or Community Worker, Solicitor, Corrections Officer?

Yes

Details of the person supporting you.

Name person supporting you

First Last

Organisation of person supporting you

Phone number of person supporting you

Email of person supporting you

Consent

I have read the eligibility criteria and guidelines.(Required)

I confirm that I have read the eligibility criteria and guidelines. To the best of my knowledge I believe I meet the criteria.

Review Eligibility Criteria here if you are not sure.Opens in a new tab

I understand it is up to me to follow up my application(Required)

To your knowledge are you related to, or do you have a relationship with, any staff or Board member or current resident of Namatjira Haven?(Required)

Yes

Not Sure

If yes, who is the staff or Board member or current resident and what is the nature of that relationship?(Required)

This field is for validation purposes and should be left unchanged.

Eligibility criteria

Looking for a place in our program? Click here to read our eligibility criteria.

Learn More

Donations

Help to support the work of Namatjira Haven.

Learn More

Home » Application Form

We regret we are not a crisis service and we can not help with urgent matters.

Apply to the Program

Personal Details

Employment / Income Status

Contact Details

Current Circumstances

Details of the person supporting you.

Consent

Apply to the Program

Personal Details

Employment / Income Status

Contact Details

Current Circumstances

Details of the person supporting you.

Consent

Eligibility criteria

Donations

Our Impact

Aboriginal men supported to improve their lives in past six years.

Improvement in well being after staying with us for 8 weeks or more

Make a Donation

Over 1 million dollars paid in wages annually to local Aboriginal people

Ways to support us

Corporate Partnerships

Philanthropy

Aunty Sandra’s Safe Haven for Women

Address

Contact us

Application Form

Home » Application Form

We regret we are not a crisis service and we can not help with urgent matters.

Apply to the Program

Personal Details

Employment / Income Status

Contact Details

Current Circumstances

Details of the person supporting you.

Consent

Apply to the Program

Personal Details

Employment / Income Status

Contact Details

Current Circumstances

Details of the person supporting you.

Consent

Eligibility criteria

Donations

Corporate Partnerships

Philanthropy

Aunty Sandra’s Safe Haven for Women

Donate Now