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

Is this form being completed as part of a family / employer intervention?

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Person completing the form: personal information


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Referral source

Alcohol / Drug Use

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Primary substance used


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Secondary substance used


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Third substance used


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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.


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Health Insurance Information

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Admission

Availability for admission:

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