Questionnaire
Drug and Alcohol Rehab Clinics Alcohol Rehab Drug Rehab Alcohol Rehab Clinics Drug Rehab Clinics Drug and Alcohol Rehab Clinics Rehab Clinics

Please provide us with as much information as you possibly can. 
All information is stored confidentially and will not be passed onto third parties without your consent.
General Information

Are you:            

The client Acting on behalf of the client
Your Name:
Client’s Name (if applicable):

Client’s relationship to you (if applicable):

Client's age:
Client's gender:
Male Female

Client’s town and country of residence:

Please describe the problem in question:
Drugs
Alcohol
Both

Other
Please specify: 

What is the pattern of use:
Daily
Every 3-5 days
Weekly
No set pattern

Please state substance used (if known):

Quantity used (if known):

Please state the length of time of use (if known):
Are you/the client experiencing any of the following side effects?:
Tremors and shakes, sweats, irrational behaviour, mood swings, anxiety or depression:
Regularly
Occasionally
Never
Do you/the client lie about the frequency and the amount of use
Yes No
Is there a family history of addiction, alcoholism or depression
Yes
No
Unsure

What is your available budget:
Limited Funds
£3,000 to £5,000
£5,000 - £10,000
£10,000 - £15,000
£15,000 - £20,000
In excess of £20,000

Do you have private medical insurance:

Yes If so, which provider:  
No

Would you like to receive details from the various clinics:

Via Telephone
Via Email
Via Email and Telephone
No contact to be made at present

Which Search Engine did you use to find First4Rehab:
Google
Yahoo
AOL
Ask Jeeves
Other (Please State)
 
Please provide us with any further information which you feel may assist us in efficiently handling your enquiry:
Contact Details

Telephone number:

Email Address:

Please reconfirm your email address:
   


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