Pre Admission Form | Perry Clayman Project PCP Rehabs

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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
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.
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.
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.

Pre-Admission Form

Your Next of Kin

Admission Information

DATA PROTECTION ACT 1998: IMPORTANT INFORMATION