Medical Detox Admission & Referral Form

Medical Detox Admission & Referral Form - Road2Recovery

This form gathers everything Road2Recovery needs to refer you for a medically supervised detox and prepare your admission paperwork. It is confidential and used only for referral and treatment planning.
Detox Admission & Referral Form

This form gathers everything Road2Recovery needs to refer you for a medically supervised detox and to prepare your admission paperwork. It takes about 10 minutes. Your information is kept confidential and is only used for your referral and treatment planning.
This form gathers everything Road2Recovery needs to refer you for a medically supervised detox and to prepare your admission paperwork. It takes about 10 minutes. Your information is kept confidential and is only used for your referral and treatment planning.
Consent to collect and process sensitive health information
Your Details
Full Name

First NameMiddle NameLast Name
South African ID Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home / Discharge Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Substance Use History
Which substance(s) are you currently using?

Other
Other, please specify
How long have you been using?
When did you last use?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Route of administration

Other
Roughly how much are you using and how often?
What withdrawal symptoms do you experience if you stop using?
History & Readiness
Have you ever been admitted to a detox unit before?
If yes, please give approximate dates and where
How would you describe your motivation and determination right now?
Preferred admission timing
Are you interested in opioid substitution treatment such as Suboxone or methadone maintenance?
If yes, who would fund this medication and where would you follow up afterwards?
Health & Safety
Medical or mental health conditions we should know about
Current medications
Are you currently pregnant?
If yes, how many weeks, and is the pregnancy booked with a clinic or doctor? Where?
Do you have any upcoming court dates or pending legal matters?
If yes, please give approximate dates so we can avoid a scheduling conflict
Who Is Responsible For Payment
This is the person who will be financially responsible for the admission account (this may be you).
Financially responsible party full name

First NameMiddle NameLast Name
ID number or date of birth
Relationship to client
Postal address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mobile number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Employer name
Employer address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
- Secondary party full name
  
  First NameMiddle NameLast Name
- Secondary party ID number or date of birth
- Secondary party postal address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Secondary party mobile number
  Please enter a valid phone number.Format: (000) 000-0000.
- Secondary party occupation
- Secondary party employer name
- Secondary party employer address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Next Of Kin
- Next of Kin Full Name
  
  First NameMiddle NameLast Name
- Next of Kin Relationship to Client
- Next of Kin Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Acknowledgement & Submit
- Today's date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Before you submit
- I acknowledge and agree to the above
- Type your full name as your signature
  
  First NameLast Name
Should be Empty:

Medical Detox Admission & Referral Form - Road2Recovery

Detox Admission & Referral Form

Your Details

Substance Use History

History & Readiness

Health & Safety

Who Is Responsible For Payment

Next Of Kin

Acknowledgement & Submit