Is this enquiry for* You Someone else. Relationship:

Your Name:*

Your Tel. Number:*

Client’s Name:*

Address:*

City:*

County/State/Region:*

Country:* United Kingdom United States of America Angola Albania Algeria Argentina Australia Austria Bahrain Bangladesh Barbados Belarus Belgium Bolivia Brazil Brunei Bulgaria Cameroon Canada Chile China Columbia Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Ecuador Egypt El Salvador Estonia Finland France Georgia Germany Greece Guatemala Hong Kong Hungary Iceland India Indonesia Iran Ireland Israel Italy Jamaica Japan Jordan Kenya Korea Kuwait Latvia Lebanon Libya Lithuania Luxemburg Macedonia Malaysia Malta Mexico Moldova Morocco Netherlands New Zealand Norway Pakistan Panama Paraguay Peru Philippines Poland Portugal Puerto Rico Romania Russia Saudi Arabia Singapore Slovakia Slovenia South Africa Spain Sri Lanka Sweden Switzerland Taiwan Thailand Trinidad & Tobago Tunisia Turkey Ukraine United Arab Emirates Uruguay Venezuela Yemen Yugoslavia Zimbabwe

Postcode/Zip:*

Gender:* Male Female

Date of Birth:* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Martial Status:* Single Married Divorced Separated

Number of
Dependants:*

Are you currently employed?* Yes No

If yes, is your employer supportive of your problem? Yes No

Is your family supportive of your problem? Yes No

Fields marked with * are obligatory

Please, select your area(s) of concern and the frequency of use:*

Do you require a detoxification?* Yes No Unshure

Have you previously received residential treatment?* Yes No

If yes, please specify:*

Year: Where:

Year: Where:

Year: Where:

Do you require?* Day Care Evening Care Residential Rehab Secondary Treatment Sober Living Housing

Length of treatment varies by facility. How long are you able to undergo treatment?*

Up to 2 weeks Up to 4 weeks Up to 8 weeks Up to 12 weeks Up to 24 weeks 24 weeks + Not Applicable

How will you fund the treatment?* Medical Insurance Self Funding State Funding

[NB - if you have no funding, FTA might be able to help]

Do you have a budget?* Yes No

If yes, please specify:*

Is there a history of mental health issues?* Yes No

If yes, please specify:*

Is there a history of eating desorders?* None Anorexia Nervosa Bulimia Nervosa Compulsive Overeating

How soon are you looking for help?* Within 24 hours Within 72 hours Within 1 Week Other

Specify:

Do you have any medical conditions?* Yes No

If yes, please specify:*

Do you have any infirmities or disabilities?* Yes No

If yes, please specify:

Fields marked with * are obligatory

Is there a history of suicide attemps? Yes No

Is there a history of self-harm? Yes No

If yes, please specify:

Is there a history of violence? Yes No

If yes, please specify:

Is there a history of arson? Yes No

If yes, please specify:

Is there a history of containment? (Prison/ Security Union/ Section) Yes No

If yes, please specify:

Year: Where:

Year: Where:

Year: Where:

Do you have injection-related viral infection? (Hep C/ HepB/ HIV) Yes No

Do you commit regular criminal activity? Yes No

Do you neglet yourself? Yes No

Do you isolate yourself in a crowd? Yes No

Do you have any housing concerns, eg No Fixed Abode? Yes No

Do you feel like you are at risk of abuse from others
or are you being bullied/ controlled/ dominated? Yes No

If yes, please specify:

Fields marked with * are obligatory

Please arrange the following statements regarding your treatment, into the order of importance to you:*

1. Distance of treatment facility from home

2. Cost of treatment

3. Length of treatment

4. I require detoxification

5. I require rehabilitation

Please explain what you hope to achieve throught treatment:*

Please provide any additional information you think might us better asist you:

Fields marked with * are obligatory