Online Application Form – Residential Rehabilitation

Please fill in this form in full, giving as much information as possible to help us ensure programme suitability and progress your application as quickly as possible. If you need any help please call Admissions on 01622 816 086.
Name
Date of birth
Present address
Contact tel. no.
Nationality
Religion
Gender
N.I. number
Marital status
How many children do you have?
What are their ages?
Name and address of next of kin
Relationship to you
Any legal actions outstanding
Details of last conviction/sentence
Details of previous convictions
Details of probation orders
Probation Officer name, address and tel. no.
Have you been in rehabilitation before?
If yes, where and when?
Which project are you applying for?
What do you hope to achieve during your stay?
Do you consider yourself to have a problem with:
Have you ever suffered from:
Please specify your mental ill health here
Are you presently taking medication?
If yes, what do you take?
Have you ever had or are you having any psychiatric treatment?
If yes, where, when and what for?
Name and address of referral agency ?
If self-referral / self-funding, please state.
Telephone of referral agency
Date vacancy required
Have you been formally assessed as needing residential rehabilitation?
Date of assessment
By whom - name and address
Has funding been agreed?
Funding agency details - name, address and tel. no.
Other comments
In sending this application, you are giving permission for us to approach funding authorities, your medical practitioner and probation officer, to progress your application, if applicable. For assistance in completing this form, please call Admissions on 01622 816 086.