Name
Email
Telephone Number
Address
Post Code
Date of Birth
GP Surgery
Other professionals I have worked with in the past year (Psychiatrist, CMHT, Drug and Alcohol Service)
Next of Kin
Relationship to You
Their phone number
Their email address
Date of proposed admission:
Duration of stay?
What is your problem substance?
Alcohol
Cocaine
Heroin
Other Opiates
Cannabis
Ketamine
Methadone
Crystal Meth
Gambling
Other Behavioural Addiction
Other problem substances or addictions?
Alcohol
Cocaine
Heroin
Other Opiates
Cannabis
Ketamine
Methadone
Crystal Meth
Gambling
Other Behavioural Addiction
Do you have any of the following?
None Current/ongoing decompensated liver cirrhosis Korsakoff’s syndrome Currentelirium tremens (DTs) is a severe, life-threatening form of alcohol withdrawal that typically occurs 2–5 days after stopping heavy drinking, characterised by confusion, agitation, hallucinations, fever, and autonomic instability, different to 'tremors / shaking' Suspected Wernicke’s encephalopathy Decompensated cirrhosis (ascites, jaundice, encephalopathy, variceal bleeding) Withdrawal seizures during a medically assisted detox Any seizure within the past month 3 or more detoxes in past 12 months Acute kidney injury or advanced CKD Severe hypertension (≥180/120 mmHg) Uncontrolled diabetes (acute complications) Acute breathing difficulties (COPD/asthma exacerbation, pneumonia) Acute pancreatitis Acute upper GI bleed Endocarditis, sepsis, or other serious infection (e.g. from IV use) Acute coronary syndrome / unstable angina / chest pain suggestive of ischaemia Acute heart failure Severe cardiac complications from stimulant use (arrhythmias, recent cardiac event) Inability to reposition independently Active or high-risk pressure ulcers Actively suicidal (intent/plan or recent attempt within past month) Acutely psychotic Requiring detention under the Mental Health Act Sexual offences Arson Serious violent offences Daily benzodiazepine dose >60mg diazepam equivalent History of life-threatening benzodiazepine withdrawal (status epilepticus) GBL use ≥30ml/day or dosing every 1–2 hours History of severe GBL withdrawal (delirium, seizures, ICU admission) Active acute eating disorder BMI below 18.5 Pregnant Lacking mental capacity to consent
Tell us more about your addiction and related issues:
Do you have any other compulsive behaviours or addictive processes?
Gambling
Over Working
Social Media
Gaming
Shopping
Over-exercising
Other (please state)
Other compulsive behaviours or addictive processes?
How would you describe your current emotional state?
Do you have any allergies? If Yes, pls list.
How would you describe your current physical health?
Are you prescribed any medication?
If Yes, please list each medication and dosage (remember to bring these with you):
Why are you entering rehab now? What’s changed for you?
What would you like to achieve by being in rehab? What would be a positive outcome for you?
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