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 tick all that apply):
 
Live-in rehabilitation - Drug and Alcohol
 
 
 
Counselling - Drug and Alcohol
 
 
 
Counselling - Mental Health
 
 
 
Other (Type of services)
 
 
 
 
 
 
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 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".
  • Personal details of the person you are enquiring for, if you are enquiring "On behalf of someone else".
 
 
Date Of Birth
 
 
Gender
 
 
 
Primary drug of concern
 
 
Secondary drug of concern
 
 
 
Primary drug of concern (other)
 
 
Secondary drug of concern (other)
 
 
 
How did you find out about Lives Lived Well?
 
 
 
 
 
 
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/