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An alcohol & drug rehab clinic

Apply for Admission Online

Filling in our online pre-admission form will help us to respond to your admission needs.  

Please note that this form helps us assess your needs but does not oblige you to treatment.  

All information will be treated as strictly confidential and will be sent and stored securely.

You need only complete as much as you can or feel able.  Once you are satisfied please click the submit button and we will respond to your submission as quickly as possible.

Prospective patient personal information
Person completing the form
Personal information

e.g. Parent, sibling, employer

Referral source
Alcohol / Drug Use
Primary substance used

e.g. Alcohol, cocaine, cannabis

e.g. Daily, weekly

Secondary substance used
Third substance used

Details of previous treatment relating to drug and alcohol use. Attendance at Alcoholics Anonymous or Narcotics Anonymous. Other relevant information.

Funding for treatment

N.B. funding via NHS or social services needs to be agreed in advance of admission. Please select 'other' if you need to access this form of funding, and give further details.

Health Insurance Information

Please include ALL Telephone numbers on your insurance ID card / recent correspondence from your insurance company:

Admission
Comments

Any comments from the person completing this form

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