Initial Application Form

DEFENDANT FULL NAME

DEFENDANT DATE OF BIRTH

Which of the following applies?

I am a Lawyer I am a Friend Other

Your Contact Email

Your Contact Phone Number

I need a NZ BASS referred Lawyer

Please provide Lawyers Name and best contact number below

Briefly explain your active charges? * e.g. dishonesty, drugs, assault, weapons etc.

Family/Whanau/Support Details - Marital Status, Spouse` & or Kids Name (s),

Please provide Emergency Contact Person & Phone Number

Do you have any affiliation to a gang/hapu/iwi? Please State

Provide us with ADDICTION (S), MENTAL HEALTH concerns or MEDICAL conditions you have? (if any)

Are you currently on or require medication?

YES NO

Provide us with as much information about the type (s) of medication you are taking

Additional Information

How did you hear about our facility?

COST/FEES for 3 Months Minimum Period + referrals to other treatment programmes:

Date

By checking this box, I acknowledge and consent to NZ Bail Accommodation & Support Services collecting, storing, and using my personal information for the purposes of assessing my application, providing accommodation, rehabilitation, and support services, and managing my engagement with the programme. I understand and agree that this may include the collection and use of sensitive personal information, including (but not limited to) health, behavioural, and background information, where relevant to my assessment and care. I authorise NZ Bail Accommodation & Support Services to share relevant information with my legal representatives, support persons, programme providers, and other parties directly involved in my application or ongoing support, where necessary and appropriate. I understand that all personal information will be handled in accordance with the Privacy Act 2020 and will only be used or disclosed for lawful purposes connected to my application and participation. I consent to being contacted via phone, email, or other electronic means regarding my application and placement. I confirm that all information I have provided is true and correct to the best of my knowledge.