Application: Intensive Driver Behaviour Change Program

Intensive Program Note alternative program delivery because of COVID-19 Virus

IMPORTANT INFORMATION
Please read before proceeding

THIS PAGE IS FOR BOOKING INTO THE INTENSIVE DRINK/DRUG DRIVER BEHAVIOUR CHANGE PROGRAM. PLEASE CHECK YOUR LETTER FROM VICROADS CAREFULLY, OR CALL THEM ON 1300 723 790, BEFORE PROCEEDING TO ENSURE YOU ARE BOOKING INTO THE CORRECT PROGRAM.

This application is for the Intensive Behaviour Change Program and requires payment of either the full course fee ($800.00) or the Concession Fee ($740.00) in order to be successfully submitted. Fees include a VicRoads recovery fee. Once your application is accepted, you will be re-directed to the payment page for payment by credit/debit card or via PayPal account. If you do not pay via the PayPal option given at the end of this application, we will not receive your information and you will not have a reservation into this program.

Odyssey House is continuing to provide the Drink/Drug Driver Intensive Behaviour Change Programs in ways that minimises the risk of spreading the COVID-19 virus.

The program will be delivered using methods such as web-conferencing for group sessions and telephone for screening and one-to-one sessions.

To participate in group sessions using web-conferencing, participants will need to have access to a laptop or desktop computer plus the application Zoom or Skype. Zoom may be downloaded for free. It is preferable that participants use Google Chrome as their internet browser.

The revised delivery methods replace the original four-week face-to-face program.

Week 1 involves a group session;

Week 2 is a one-to-one session between each participant and our facilitator. You will be advised of the day and time for this part of your program by the facilitator or the coordinator prior to commencing the program. If you wish to finalise your one to one appointment time now you can contact the BCP Coordinator on (03) 8537 7115 or 0468 514 183 or by email to driverbchange@odyssey.org.au to arrange an appointment. Alternatively, we will contact you to arrange an appointment no later than 1 week before the start of your Program.

Weeks 3 and 4 are group sessions.

In order to participate fully and meet VicRoads requirements, you must be available for all sessions and agreed program times. Please ensure you can be contacted via your nominated phone number to enable us to conduct screening prior to the program and or via email to finalise the booking. You must respond to us 2 weeks before the commencement of the program in order to be eligible to participate. Please make sure you check your phone and email regularly.

You must attend all of these sessions in order to successfully complete the program. Failure to do so means you will forfeit all fees paid.

If you have any questions about this, or would like to discuss your application please contact the Program Coordinator on (03) 8537 7115 or 0468 514 183.

Your personal details

Please provide us with your name and personal contact details, date of birth, gender, VicRoads licence or customer number

Surname

First Name

Gender

Female

Male

Indeterminate/Intersex/Unspecified

Date of Birth

License /VicRoads Client Number

(Note: Your License Number may be located on your driver's license/learner's permit. Alternatively, your Client Number can be located on your letter from VicRoads advising you to complete the Program. Please contact VicRoads if you have difficulty obtaining this information.)

Your Mobile Number

Your E-mail Address

Street Number & Name

Address - Home - Street/Lot Number

Address - Home - Street Name

[Home] Address -

Lookup

Manual Entry

[Home] Address -

Lookup

Manual Entry

[Home] Address - Lookup

[Home] Address - Overseas State/Province

[Home] Address - Suburb

[Home] Address - Post Code

[Home] Address - Street Address 1 - House/Unit Number

[Home] Address - Street Address 2 - Street Name

[Home] Address - Unit/Flat Number

[Home] Address - Street/Lot number

[Home] Address - Street Name

[Home] Address - State

[Home] Address - Country

Please provide us with details of eligibility for a concession or if another person / organisation is paying the program fees on your behalf

Is another person or organisation making the payment?

Yes

Email of other person/organisation making the payment

Mobile Number of other person/organisation making the payment

Are you eligible for a concession discount?

Yes

If eligible for a concession discount:

Please attach a scanned copy or photo of your Eligible Concession Card. (Valid Healthcare Card, Pensioner Concession Card or Seniors Health Card)

Please note: This concession card will need to be presented on the first day of the course. If not, the full price difference will need to be paid at that time.

Additional information to help us

On this page we ask some questions to assist us to ensure the program meets your needs.

How did you hear about us?

Please outline if you answered Other above

Tell us about your English language skills

English is my preferred language

I have difficulty speaking and understanding written English language

I need the assistance of an interpreter in order to participate fully in a behaviour change program

Please tell us about your experience or understanding of small group work

I am confident in participating in small groups

I have never participated in a small group session before

I am nervous about what might be expected of me in participating in a small group

Tell us about your skills in using computers and web-conferencing

I have good skills in using computers and web-conferencing

My skills in using computers and web-conferencing are not very good

I can get help to enable me to participate to use a computer and web-conferencing to participate in the program

Please tell us about how urgent it is for you to participate in the program

It is urgent for me to complete this program as soon as possible

I can wait for a month to complete this program

I can wait for two months to complete this program

If you answered urgent to the question above please tell us why it is urgent

It is urgent for me to complete this program because of a court order and their timeline

It is urgent for me to compete this program because of my work commitments

It is urgent for me to complete this program because of family commitments

It is not urgent for me to complete this program because of a court order timeline

Please tell us about any nervous or mental health issues

I do not have any mental health issues

I am receiving help for a mental health issue

I am anxious about participating in small group work

I am not anxious about participating in small group work

I prefer not to answer this question

PARTICIPANT ACKNOWLEDGEMENT AND CONFIRMATION OF UNDERSTANDING OF PROGRAM REQUIREMENTS

I confirm and agree to:

Please enter your name here as a form of digital signature agreeing to the above.

Payment

Note: If you don't process payment at this stage, we will not receive your application and you will not have reserved a spot in this program.

If you are claiming an eligible concession, you must submit a scanned copy or photo of your concession card in the previous page of application. Presentation of evidence of eligible concession will be required on the first day of this program or the full fee price will need to be paid.

Applicants who have not paid their full course fees will not be able to reserve a spot in this course.

We require five business days' notice of any changes to your nominated course dates - or you may forfeit your course fees. See our full policy regarding course changes, cancellations at https://odyssey.org.au/what-we-do/education-services/drink-and-drug-driver-behaviour-change-programs/

Payment Options

Intensive Drug BCP Full Fee	$800.00
Full Fee	$800.00
Intensive Drug BCP Concession Fee	$740.00
Concession Fee	$740.00

Subtotal: $800.00

Tax: $0.00

Total: $800.00