Pre-Admission Form

Take the first steps in your recovery like so many others have, Fill out our form below, and a member of our admissions team will contact you to explain the next steps. Don’t be afraid; this is the hardest step, and we will be with you all the way. If you are still anxious or nervous about booking in, take a look at what our most recent clients had to say about their experience with PCP.

If you have booked your place at one of our rehabs, please complete the following form. Please note the information we require is about the patient, our preference is that this form is completed directly by them; if this is not possible, a family member, friend, of professional can complete it on the patient’s behalf. The more information you can provide at this stage, the better, however if you are unsure of anything, don’t worry.

All fields with an asterisk (*) are mandatory, if you don’t know the answer to any of the questions, please get in touch with one of our advisors.

Once you have completed the form, a member of our nursing team will be in touch, to prepare you and us for a safe admission into the service.

Pre-Admission Form

Name*
First Last
Gender*
Address*
Street Address City ZIP / Postal Code
Date of Birth*
DD slash MM slash YYYY
Email*
Phone*
GP Surgery*

(we will not contact your GP without your signed consent to do so)
GP Surgery Location*
Your Next of Kin
Full Name (Next of Kin)*
Relationship to You*
Phone*
Consent*
I consent to PCP contacting my next of kin prior to treatment.
Admission Information
Date of proposed admission to PCP?*
DD slash MM slash YYYY
Duration of stay?
PCP rehab location?*
What is your problem substance?*
Other problem substances or addictions?
Please describe frequency and amounts of current usage, together with a brief history of when your using/drinking got out of control:*
Are you taking or prescribed any medication?*
If Yes, please list each medication and dosage (remember to bring these with you):
Do you have any physical or mental health conditions?*
If Yes, please describe:
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?*
How did you hear about PCP?
To ensure that PCP can effectively and safely manage my care, I confirm that within 24hours (to account for intoxication), I shall have the ability to walk up and down stairs, wash and dress independently and remain continent, PCP is unable to provide this level of care*
I agree with the above statement*
To ensure that PCP can effectively and safely manage my care, I confirm that within 24hours (to account for intoxication), I shall have the ability to walk up and down stairs, wash and dress independently and remain continent, PCP is unable to provide this level of care
I fully confirm and understand that the payment made by debit/credit card or bank transfer or which has been made on my behalf is non-refundable and that a place has been reserved for me to attend PCP.*
I agree with the above statement.*
I fully confirm and understand that the payment made by debit/credit card or bank transfer or which has been made on my behalf is non-refundable and that a place has been reserved for me to attend PCP.
DATA PROTECTION ACT 1998: IMPORTANT INFORMATION
PCP 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 PCP in providing treatment; including but not limited to information technology service providers.*
I understand, agree and accept this data policy.*
PCP 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 PCP in providing treatment; including but not limited to information technology service providers.
I fully acknowledge that I have read, understood and agree to PCP's Terms and Conditions of business, service information guide and treatment contract.*
I fully agree to the terms and conditions of business, service information guide and treatment agreement. *
I fully acknowledge that I have read, understood and agree to PCP's Terms and Conditions of business, service information guide and treatment contract.

A Straightforward and Welcoming Process

Rehab Today by PCP understands that admitting to rehab for addiction treatment or detox can be a frightening prospect for most. For the vast majority of individuals who come to us for help, it is a slow process of surrendering to the fact that they cannot carry on as they are any longer. Admission to one of our rehab centres is one of the most courageous and worthwhile things you can do, not just for your family, but for yourself.

Immediate and Emergency Rehab Admissions

Rehab Today by PCP appreciates that, due to the nature of addiction, many individuals will only accept help when they see no other way out of their increasingly painful situation. This means that most people who contact us require immediate admission after reaching a crisis point. We are dedicated to meeting our patients’ treatment needs. We understand the need to act quickly and professionally in response to a request for help. Rehab Today by PCP has a dedicated emergency admissions team on standby 24/7, to ensure that you or your loved one are admitted as quickly and as seamlessly as possible, usually within 24 hours of contacting us.

Pre-booked Rehab Admissions

If you have decided to admit to one of our rehabs but have some business or family matters to take care of first, we can book you an admission date upon receipt of a deposit. A treatment bed will then be held open for the date you decide on.

Getting Here

Rehab Today by PCP has 4 treatment centres in various UK locations. All are easily accessible by public transport or by car. If you are not able to get yourself here, please call us in advance of admission to discuss possible sober transportation. Whether you are admitted to our London, Luton, Chelmsford or Leicestershire rehab clinic, you will be provided with the full address, contact number and details of how to get there.

Complete Confidentiality

Rehab Today by PCP respects our patients’ right to have their admission and treatment kept confidential. You can, therefore, be assured that we will not give out your details to anyone. We will not even confirm your admission unless that person is on your approved contact list. Even then, no personal details of your treatment will be disclosed.

What to Expect on Admission to Our Rehab

When you arrive at your chosen location, you will receive a very warm and friendly welcome from our rehab team, who will be expecting you. You will be shown around the rehab to familiarise yourself and introduced to the clinical team and other patients. Any outstanding paperwork will also be completed prior to treatment commencing and you will be presented with a timetable of our addiction treatment therapies and break times.

On the first day of admission, we try to keep things as simple as possible so as not to overwhelm you. You will, therefore, meet with your focal counsellor on your first or second day of admission, depending on how you are feeling.

Comprehensive Medical Assessment

Once admitted, you will undergo a comprehensive medical assessment, conducted by our friendly rehab doctor. Our doctor will take a detailed history of your addiction, current medications, and any physical and/or mental health problems.

Where alcohol and/or drug dependency is established, a medical detox regime will be prescribed to alleviate withdrawal symptoms. This also helps to ensure your safety whilst detoxing and minimises any discomfort. Your physical and mental health will be regularly monitored throughout the treatment process. For further information or answers to any questions you may have in relation to our admissions process, please speak to a member of our Rehab Today by PCP team and read our ‘what to bring to rehab’ section.

Pre-Admission Form

Pre-Admission Form

Your Next of Kin

Admission Information

DATA PROTECTION ACT 1998: IMPORTANT INFORMATION

A Straightforward and Welcoming Process

Immediate and Emergency Rehab Admissions

Pre-booked Rehab Admissions

Getting Here

Complete Confidentiality

What to Expect on Admission to Our Rehab

Comprehensive Medical Assessment

Contact Us

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Policies & Important Info

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