Road2Recovery – Pre-Admission Form
Complete this brief pre-assessment to help us understand the situation before your first conversation with a counsellor.
Everything you share here is 100% private and confidential, protected under POPIA, and only ever used to prepare for your assessment.
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
Consent
E-signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: