Personal Information Date of Contact (required) Date of Birth (required) Client's Surname (required) Other Names (required) Gender (required) MaleFemale Location (required) Postal Address Telephone Number (required) Family Information Father's Name Father's Status --Select Status--LivingDeceased Mother's Name Mother's Status --Select Status--LivingDeceased Number of Siblings Birth Order Position Marital Status Marital Status --Select Status--MarriedSingleDivorcedSeparatedOther Spouse Name (if married) Number of Children --Select--None1-34-67-910 or more Education & Health Highest Education Level --Select Level--NonePrimarySecondaryCollegeUndergraduatePostgraduate Occupation/Previous Occupation Driver --Select--YesNo Health Issues --Select--YesNo Health Issues Details Contact Personal Doctor --Select--YesNo Doctor's Name Doctor's Telephone Drug Problem Information Main Drug Problem --Select Drug--CannabisHeroinOther opioidsCocaineAmphetamineEcstasyAlcoholTobaccoKhat (miraa/muguka)Other How Long (years) Injecting Drug Use --Select--YesNo Previous Treatment --Select--YesNo Ever Decided to Quit --Select--YesNo Emergency Contacts Contact 1 Relationship Contact 1 Telephone Contact 2 Relationship Contact 2 Telephone Contact 3 Relationship Contact 3 Telephone Agreement I agree to undertake the treatment program and abide by all the rules and regulations of the rehabilitation center. Reclaim your life. Your new beginning starts here. Our comprehensive program includes individual therapy, group sessions, and holistic wellness activities—all included in your treatment plan.
