Pre-Admissions - TLC Rehab

Thrive. Learn. Conquer.

Pre-Admission Form

Thank you for making the decision to enter treatment here with us at TLC Rehab. Our first priority is to keep you safe, so it is important for us to have as much information as possible about your health prior to you entering treatment. Please complete the following form to the best of your ability. This form can be filled out on your behalf, by a family member, friend, of other healthcare professional.

Fields marked with an asterisk (*) are required. If you’re uncertain about anything, please give us a call. Please also try to obtain a copy of your own medical summary, via the NHS app or by calling your surgery.

Once you have submitted this form, a member of our nursing team will call you to discuss the next steps.

Name

Telephone Number

Address

Post Code

Date of Birth

GP Surgery

Please list any other healthcare professionals you are in contact with (Community Drug & Alcohol Team, CMHT etc)

I consent to TLC Rehab contacting my GP and any other healthcare professionals, prior to my treatment starting.

Next of Kin

Relationship to You

Their phone number

Their email address

I consent to TLC Rehab contacting my Next of Kin prior to treatment.

Date of proposed admission:

Duration of stay?

What is your problem substance?

Other problem substances or addictions?

How much? How often? When was your last period of abstinence?

Are you prescribed any medication?

If Yes, please list each medication and dosage (remember to bring these with you):

Do you have any physical health conditions?

If Yes, please tell us more:

Do you have any mental health conditions?

If Yes, please tell us more:

Have you ever had a detox or been in rehab before?

If Yes, please give details:

Do you have a history of seizures whilst on detox?

If Yes, please give details:

Have you had any hospital admissions in last 6 months?

If Yes, please give details:

Levels of Care

To ensure that TLC Rehab can effectively and safely manage my care, I confirm that within 24 hours (to account for intoxication), I shall have the ability to wash and dress independently and remain continent, TLC Rehab is unable to provide this level of care

Data Protection / GDPR

TLC Rehab will create and maintain computer and paper records relating to you, prior to, during and after you leave treatment; these records will be processed in compliance with the Data Protection Act 1998. Please indicate your acceptance that by ticking this box you fully understand that you are providing consent that the information in these records may be shared both internally within PCP and to external organisations working with TLC Rehab in providing treatment; including but not limited to information technology service providers.

Terms and Conditions

I acknowledge that I have read, understood and agree to TLC Rehab's Terms and Conditions of Treatment.

Thrive. Learn. Conquer.

Pre-Admission Form

PRIVACY COMMITMENT

LOCATION

SERVICES

OPENING HOURS