Can you please complete the below information. Your answers will help us to best direct your enquiry to the most suitable service.
 
Are you enquiring for *
 
 
 
Please tell us what your enquiry relates to
 
 
 
 
 
 
What type of service are you looking for (please select most suitable option):*
 
 
 
If “Other” is selected above please provide brief description
 
 
 
 
 
 
What region are you able to access service in?*
 
 
 
Your contact details (Enquirer's details).
Please provide a Mobile number or an Email address so that we can contact you back. 
 
Your First Name*
 
 
Your Last Name*
 
 
 
Your Address*
 
 
 
Your Suburb*
 
 
Post Code*
 
 
 
Preferred method of contact*
 
 
Email
 
 
 
Your Email*
 
 
Your Mobile*
 
 
 
A valid email address is required to submit this enquiry. Please call LLW on 1300 727 957 for assistance if you do not have a valid email address. 
 
 
 
 
Personal Details.
  • Your Personal details if you are enquiring for "Yourself".
 
 
Date Of Birth*
 
 
Do you have children under the age of 18 in your care?*
 
 
 
Indigenous Status*
 
 
Gender
 
 
 
Country Of Birth
 
 
Preferred Language
 
 
 
Primary drug of concern
 
 
 
 
Primary drug of concern (other)
 
 
 
 
Identifies as LGBTIQ
 
 
Personal Referral Source*
 
 
 
Usual Accomodation
 
 
Living Arrangement
 
 
 
Source Of income
 
 
Legal Status
 
 
 
How did you find out about Lives Lived Well?*
 
 
 
 
 
 
Emergency Contact Details
 
Emergency Contact Name*
 
 
Emergency Contact Phone*
 
 
 
Emergency Contact Email
 
 
Emergency Contact Address
 
 
 
 
 
 
In submitting this enquiry, you consent to being contacted by a Lives Lived Well staff member.**
 
 
 
 
 
 
Please refer to Lives Lived Well Privacy Policy for more information: https://www.liveslivedwell.org.au/1623-2/