Road2Recovery – Pre-Admission Form
Complete this brief pre-assessment to help us understand the situation before your first conversation with a counsellor.
Section A – About the Person Seeking Help
Full name
*
First Name
Middle Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ID or passport number
Contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Physical address / suburb
Preferred language
Section B – About You (if completing this form on someone else's behalf)
Your full name
*
First Name
Middle Name
Last Name
Your relationship to the person above
*
Self
Parent
Spouse / Partner
Family member
Employer
Other
Contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Section C – Presenting Concern
What is most concerning you at the moment?
*
Alcohol
Heroin
Other opioids
Cannabis
Methamphetamine (tik)
Cocaine
Prescription medication
Gambling / other behavioural addiction
Other
How long has this been a concern?
Is the person currently using, and when was the last use?
Has the person received treatment or counselling for this before? If yes, please describe briefly.
Has a medical professional been involved?
*
Yes
No
Not sure
Section D – Health & Wellbeing Screening
Medical conditions or chronic medication taken
Ever experienced seizures, blackouts, or severe withdrawal symptoms when stopping use?
*
Yes
No
Not sure
Mood or stress levels over the past two weeks
*
Coping well
Struggling at times
Struggling significantly
Support system at home (family, friends, community)
*
Yes
No
Somewhat
If there is any immediate risk to the person's safety today (a medical emergency, intoxication requiring urgent care, severe withdrawal, or thoughts of self-harm), please do not wait for a response to this form. Contact us immediately at 071 887 4326 / 084 416 8088, or go to your nearest emergency room.
Section E – Practical Information
How did you hear about Road2Recovery?
*
Self-search
Family or friend
Employer
Court order
Other
Is the referral court-mandated?
*
Yes
No
How will the care be covered?
*
Medical aid
Self-funded
Not sure yet
Preferred format for sessions
*
Face-to-face in Crawford
Online
Either
Best day(s) and time(s) to reach you
Section F – Affordability & Fit Questionnaire
Please complete this brief questionnaire to help us understand your current financial alignment and determine the best service tier or payment structure for your goals.
Part 1: Service Tier Alignment
Select the service package or offering you are most interested in exploring:
Tier 1: Individual Coaching / Mentorship Sessions
Tier 2: Group Wellness & Professional Development Workshops
Tier 3: Comprehensive Corporate / Organizational Wellness Program
Tier 4: Community Support & Resource Access
Part 2: Monthly Financial Snapshot
To ensure our pricing remains sustainable for your budget, please estimate your current monthly financial allocation:
What is your comfortable monthly budget range for professional wellness or support services?
Under R1,000 / month
R1,000 – R3,500 / month
R3,500 – R7,500 / month
R7,500+ / month
How do you anticipate funding these services?
Self-funded (Personal budget)
Employer-sponsored / Corporate Professional Development budget
Grant-funded, Sponsorship, or Sliding-scale requirement
Part 3: Commitment & Investment Horizon
Our programs yield the best results with consistent engagement. Please select your preferred timeline:
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Short-term intensive (1 month / Single project)
Medium-term engagement (3 months)
Long-term partnership (6+ months)
Part 4: Payment Structure Preferences
We offer flexible payment options to accommodate different financial workflows. Which structure works best for you?
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Upfront Payment: Pay in full (eligible for a standard administrative discount)
Monthly Installments: Automatic recurring monthly deductions
Custom Plan: Requires a discussion regarding alternative arrangements or sliding-scale availability
Next Steps & Internal Review
Note: Once submitted, our team reviews your responses to match you with the most appropriate service tier or discuss flexible structuring if needed.
Consent
E-signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Everything you share here is 100% private and confidential, protected under POPIA, and only ever used to prepare for your assessment.
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