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Drug and Alcohol Clinic Admission

Admission Questionnaire

Once you have made the decision to seek intervention through rehabilitation, either for yourself, for a family member or for a friend, we only ask you to fill out the following information and email or fax it back to us. Then we will take care of all necessary arrangements, and get back to you as soon as possible

Please take the time to fill this out as accurately as possible. We will treat this information with confidentiality and only pass it on to the correct professionals in order to make an informed decision. Thank you for your time and patience.

If you experience any difficulties, please don’t hesitate to Contact Us.

Privacy Policy

The information you provide will be treated in strict confidence and will not be disclosed to a third-party except in connection with any treatment that we arrange on your behalf.