Application: Intensive Driver Behaviour Change Program

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 ($817.00) or the Concession Fee ($784.00) 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 Face to Face and Telephone for screening (a one-on-one session with the facilitator)

Week 1: Group session

Week 2: is a one-to-one session between each participant and the facilitator. It will take approximately an hour, sometimes longer or shorter. These sessions are face-to-face or via Zoom. The day and time of that session will be discussed during session one (in week 1) with the facilitator. You must be available for the agreed appointment time in order to complete the program.

Week 3: Group session

Week 4: Group session

In order to participate fully and meet VicRoads requirements, you must attend all sessions and agreed program times. Failure to do so means you will forfeit all fees paid.

Please ensure you can be contacted via your nominated phone number to enable us to conduct pre-screening prior to the program and or via email to finalise the booking. Please make sure you check your phone and email regularly. The facilitator will endeavor to contact you prior.

You must attend on time to every session. If you are more than 10 minutes late you will not be admitted to the session, and you will need to reschedule your booking. This may result in extra cost to you and may result in starting the program again.

Please ensure you have a copy of your VicRoads letter ready to upload, instructing you to complete this particular program before proceeding with this application. You can obtain a copy by emailing VicRoads at DDD@roads.vic.gov.au

Before proceeding with your application, please ensure you have the following:

- A copy of the VicRoads Letter (stating which program you are required to complete)

- Your Concession card (if applicable) to upload

- Photo ID (to show before your program commences)

If you have any questions or would like to discuss your application please contact the Odyssey DDDBCP Admin Team on (03) 8537 7115 or mobile 0468 514 183. The DDDBCP Admin Team may also be contacted via email at driverbchange@odyssey.org.au

Your personal details

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

It is important that we have the correct information provided to us, for your certificate of completion, which you will need to provide to VicRoads for relicensing.

Please ensure all your details are correct as we are required to contact you via both telephone and email. Failure to provide correct details may result in not being able to participate in the program.

Surname*

First Name*

Gender (Select one only)*

Gender identity not stated

Female

Male

Indeterminate/Intersex/Unspecified

Preferred Pronouns (optional)

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* (please ensure you enter this correctly)

Your E-mail Address*

Street Number & Name

[Home] Address -

Lookup

Manual Entry

[Home] Address -

Lookup

Manual Entry

[Home] Address - Lookup

[Home] Address - Overseas State/Province

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

[Home] Address - Street Address 2 - Street Name

[Home] Address - Unit/Flat Number

[Home] Address - Street Number*

[Home] Address - Street Name*

[Home] Address - Suburb*

[Home] Address - Post Code*

[Home] Address - State*

[Home] Address - Country*

Please tell us if you are eligible for a concession discount and provide information about another person or organisation that may be paying your fees for the program.

Other information to assist us

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.

Centrelink (eServices Australia) Consent

I authorise Odyssey House Victoria to use Centrelink Confirmation eServices to perform a Centrelink enquiry of my customer details in order to enable the business to determine that my concession card is current and valid.

I authorise Services Australia (the agency) to provide the results of that enquiry to Odyssey House, Victoria.

I understand that Services Australia will disclose personal information to Odyssey House staff who conduct the Drink and Drug Driver Program with information including my name, payment type, payment status, one off payment, income, deductions, assets, shared care and partner status and concession entitlement based upon evidence I have provided to Odyssey House within this application and that Odyssey House staff will use this information only for the purposes of my involvement in the DDDBCP program in relation to charging concession rates for fees due

I understand this consent, once signed, remains valid while I am a client of Odyssey House Victoria unless I withdraw it by contacting the Odyssey House Victoria or the agency.

I understand if I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be able to enter into required payment arrangements I may not be able to access the concession rate

Please type your Full Name below as a form of digital signature agreeing to the above

Sign Here:*

Date

VicRoads Letter

Please upload / attach a copy of your letter from VicRoads advising you that you are required to complete the Program. Contact VicRoads on 1300 723 790 or DDD@roads.vic.gov.au if you have difficulty obtaining this. ***You must provide us with a letter or the email from VicRoads to successfully enroll in the program. If you have not received a letter or email from VicRoads, you will not be able to continue with this enrolment until you obtain a copy of the letter from VicRoads and provide it to us. The letter must state which program you are required to complete.

Photographic Identification

In order to participate, you will need to provide photographic ID that identifies you and your current address, as registered with VicRoads. If you need to provide additional evidence to demonstrate your identity and current address, please read VicRoads’ standards of acceptable identity documents https://www.vicroads.vic.gov.au/licences/evidence-of-identity/types-of-identity-documents

You can upload multiple documents below

You will also need to bring your ID documents with you on the day of the program

Who is this booking for?

This booking is for me. I am booking for myself.

This booking is for someone else. I am booking on behalf of the client (please enter details below)

Contact Details and Relationship to the client

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

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

Do you require a Support Person?*

Yes (If yes, please contact the Program Coordinator before making a booking)

Do you require an Interpreter?*

Yes (If yes, please contact the Odyssey DDDBCP Admin Team before making a booking) - Please do not continue with this booking

Tell us about your English language skills*

English is my preferred language

I have difficulty speaking and understanding written English language - Please call Odyssey DDDBCP Admin Team to discuss before enrolling

I need the assistance of an interpreter in order to participate fully in a behaviour change program - Please do not continue with this booking

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

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

Informed Consent

This page is to be completed and signed by DDDBCP program participants as evidence of their willingness to participate in the Odyssey DDDBCP program and as confirmation of their understanding of conditions of participation and their responsibilities within the program.

I understand and agree to:*

Attend each session at least 20 minutes prior to commencement time

Wear appropriate clothing to each session

Provide photo identification to the facilitator at the first session

Participate in all sessions for the program I have booked

Respect the rights and views of others in the group

Contribute to a safe and inclusive therapeutic environment

Behave in a way that is not disruptive nor aggressive and understand that such behaviour is unacceptable and will result in expulsion from the group

Maintain the privacy and confidentiality of all other participants in the group sessions outside of the program (particularly not mentioning others in the groups' names)

Additionally, I understand and agree that:*

If I have not provided Odyssey with accurate information regarding the need for interpreter services, that I may be asked to leave the program and forfeit all payments made.

I understand that Odyssey does not provide interpreter services for those with written and spoken English difficulties

I have communicated to Odyssey my need for a support person to be present at sessions, and that the support person's privacy and consent agreements are to be provided to the Odyssey DDDBCP Admin Team prior to the session

I understand that all personal information provided by me to Odyssey House Victoria will be retained in a secure database. Privacy and confidentiality are assured, except in the following circumstances;

- Information about me is provided to VicRoads
- Information will be disclosed if there is concern of you hurting yourself and/or other people
- As part of the registration and participation in the program, information will be shared amongst the
Odyssey DDDBCP Team
- As part of a formal process of professional support and learning all facilitators participate in clinical
supervision. During this process, information about you may be shared, all staff are bound by privacy
legislation and your details will be kept private.

I understand that group sessions may be recorded and used for facilitator training purposes only, and that the recordings will be deleted after use and not kept beyond 6 weeks.

I agree that information about me can be shared with other services for purposes of referral for additional support

I understand that I can register a complaint or concern or to provide positive feedback to Odyssey House or VicRoads via their website.

I understand that should I need to cancel my booking, I must provide Odyssey with a minimum of 5 days before the start date of the program to avoid forfeit of all payments made.

I understand that family, partners, friends or carers are not permitted in any of the programs.

I have read and understood the conditions of Drink/Drug Driver Behaviour Change Program. All questions I have asked have been answered to my satisfaction.*

I agree to the conditions described including those above, the arrangements for disclosing information, and agree to be an active participant in the program.

I confirm all the information provided by me in this application is true and correct

Please type your Full Name below as a form of digital signature agreeing to the above

Sign Here:

Date*

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 on the previous page of the 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 program dates - or you may forfeit all fees paid. 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 BCP Full Fee	$817.00
Intensive Behaviour Change Program (Full Fee) - $750.00	$750.00
VicRoads Program Fee (Full Fee) - $67.00	$67.00
Intensive BCP Concession Fee	$784.00
Intensive Behaviour Change Program (Concession) - $750.00	$750.00
VicRoads Program Fee (Concession) - $34.00	$34.00

Subtotal: $817.00

Tax: $0.00

Total: $817.00

This course is currently not open for enrolments