Private Bag 1, Kareedouw, 6400 Route 62, Kareedouw REPUBLIC of SOUTH AFRICA

MOOIUITZICHT

TREATMENT

CENTRE

Private Bag 1, Kareedouw, 6400 – Route 62, Kareedouw – REPUBLIC OF SOUTH AFRICA

Tel: +27 42 2880 262 *Cell +27 79 4905 042 *Emai:

Client Admission Form

Complete the following information below electronically or by hand (print and fill out). Submit via email to

A staff member will contact you within 24 hours.

Client Information:

Name:

(First)(Middle Initial)(Last)

Address:

Street/PO Box

City/Town:

Age:I.D No:

Medical Aid:

Medical Aid Number:

Expiry Date:

Requested Admission Date:

Funding Guarantor (if different from client):

Name:

Source of Information (if different from Client or Guarantor):

Name of person completing this application:

(First)(Last)

Relationship to Client

Telephone Numbers

Home:Work:

Cell:

Client Admission Form p2Mooiuitzicht Treatment Centre

Emergency Contact Information:

Name of person to contact in an emergency:

Relationship to client:

Home phone number:

Cell phone number:

Referring Professional:

Name of professional working with client:

If Other, please specify:

Does professional require client progress updates? Yes /No

Contact phone number:

Contact e-mail:

Required frequency of updates (check all that apply):

Notes regarding client progress updates:

Advise frequency of contact requested and preferred mode of communication:

2. Medical History (Biomedical Complications)

Primary Physician

City/Town

Prov:

Office Telephone Number

Have you had any medical conditions/illnesses within

Are you taking any prescribed medications? No/Yes (Specify)

Are you taking any over-the-counter drugs? No/ Yes (Specify)

If yes to either question, please provide name, dosage, duration of use, and reason taken.

Have you been hospitalized in the past year? Yes No

Have you ever attempted suicide?

YesNo

If yes to either question, please describe and provide date(s).

Client Admission Form p2Mooiuitzicht Treatment Centre

Please identify any known allergies.

Do you snore or have problems sleeping?

YesNo

Are you able to walk, feed, dress and care for yourself independently? Yes No

3. Psychological History (Emotional/Behavioral)

Are you currently seeing a psychiatrist?

YesNo

Name of psychiatrist?

Are you currently seeing:

Office Telephone Number

Have you had any psychological/emotional problems in

4. Alcohol/Drug History

Complete for alcohol or any other addictive substances you have used (including nicotine) in the past 6months.

Name of Drug

Pattern of use (daily, weekend, binge)

Amount used per occasion

Length of use

Date of last use

Name of Drug

Pattern of use

Amount used per occasion

Length of use

Date of last use

Name of Drug

Pattern of use

Amount used per occasion

Length of use

Date of last use

Name of Drug

Pattern of use

Amount used per occasion

Length of use

Date of last use

5. Treatment History

Have you previously been to treatment?

YesNo

If “Yes,” please detail the history. If you require more space, please insert extra page(s).

Client Admission Form p3

Name of Program

Where located

When

Inpatient or residential?

Outcome (length of abstinence)

Name of Program

Where located

When

Inpatient or residential?

Outcome (length of abstinence)

Name of Program

Where located

When

Inpatient or residential?

Outcome (length of abstinence)

Mooiuitzicht Treatment Centre

6. Family

Ages of children?

Is there a family history of alcohol/drug use or dependence? Yes No

If yes, please describe.

Person #1

First and Last Name of Family Member or Other Loved One:

Email Address:

Preferred Phone Number:

Person #2

First and Last Name of Family Member or Other Loved One:

Email Address:

Preferred Phone Number:

Person #3

First and Last Name of Family Member or Other Loved One:

Email Address:

Preferred Phone Number:

Person #4

First and Last Name of Family Member or Other Loved One:

Email Address:

Preferred Phone Number:

Client Admission Form p4

Family Program Participation

Is Person #1 to #4 is interested in participating Family Program? Yes/No

If so, please detail:

8. Legal History

Have you ever been charged or convicted with a Criminal Code offence(*)?

YesNo

If yes, please describe (include DUIs).

If yes, do you have any pending hearings? Yes No

Mooiuitzicht Treatment Centre

9. Nutrition

Do you have any special dietary concerns?

YesNo

If yes, please describe.

10. Recovery

Please identify any strengths or resources for recovery, e.g., family support, employer support, personally motivated, etc.

Please identify any current obstacles to treatment or recovery.

Thank you. If you have any questions regarding thisapplication or prefer to complete the questionnaire over the phone, please contact us at +27 42 2880 262 /

+27 79 4905 042 or email: