If you want emergency assistance, fill out the emergency assistance form by clicking here.

If you want to apply for our womens/mens residential treatment center, fill out the assessment form below.

Assessment Form

Please download the Doctor's Form below and ask your doctor to complete it. Then scan it and upload it in the last step of the assessment form below.

Download Doctor's Form here

TitleFull NamePhone Number

Marital Status

Email

Address (include city/town)

Type of accomodation

AloneSpouseParentsOther

Do you own a home or an apartment?

YesNo

Are you a council tenant?

YesNo

Your date of BirthPPS numberNationalityDoctors nameDoctors telephone numberDoctors AddressAre you currently employed?

Summarise your employment history below

Are you receiving any of the following benefits?

Universal CreditESA (Employment Support Allowance)PIP (Personal Independance Payment)

Do you smoke?

Do you drink?

Do you use any of these drugs?

HeroineMethadoneDiazepamEcstacy

Do you use any other drugs not mentioned above?

Are you taking any prescribed medication?

Have you received any previous treatment for drug or alcohol abuse?

YesNo

Have you ever been in the Tiglin programme before?

Have you ever committed acts of physical violence against staff or other residents in a place where you were living?

YesNo

Have you ever lived in a supported housing environment?

YesNo

Where have you lived over the past 2 years?

Who has provided support to you over the past two years (e.g. professionals, workers, voluntary groups, religious organisations, family members)?

Does a social worker or a drug/alcohol agency support you?

YesNo

Do you have a probation officer?

YesNo

Have you ever seen a Psychiatrist?

YesNo

Describe about when you experienced mental or emotional health problems

Do you have a criminal record?

Have you ever been to prison?

YesNo

Do you have any outstanding warrants?

YesNo

Do you have any outstanding court appearances?

YesNo

Have you ever been prosecuted for a violent offence?

YesNo

Have you ever been prosecuted for a sexual offence?

YesNo

Have you ever been prosecuted for arson?

YesNo

Are you subject to any form of statutory supervision or probation?

YesNo

Please put in your own words why you want to come to Tiglin Ireland and live in a supported housing environment

UPLOAD DOCTOR'S FORM BELOW (FILLED UP & SCANNED PDF/WORD DOC)

Upload File

Max file size 10MB.

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fileuploaded.jpg

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DECLARATIONI agree to give Tiglin permission to act on my behalf regarding my benefits and acquire any information concerning my medical history from my doctor throughout the duration of the programme.I have completed this application form truthfully and to the best of my knowledge. I understand that any misleading information could jeopardise my entrance into the programme or my remaining on it.

Please type your name in the box below to sign the declaration:

Thank you! Your submission has been received!

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Assessment Form

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