Reintegration House Structured Recovery · South Africa

DOC-02 · Confidential Intake

Resident Admission & Screening Form

A confidential intake form completed at the point of admission. The information disclosed here is used to assess suitability for residence, manage medical safety and plan your individual recovery programme. Honest disclosure protects you and keeps the residence safe.

POPIA compliant Encrypted in transit Auto-saves every 30 seconds 14 sections · ~25 min to complete

Personal Particulars

Your identification and contact details. All fields marked with a soft cue are required for admission.

Full Names Preferred Name Identity Document Type Document Number Date of Birth Age Gender Nationality Home Language Other Languages Spoken Marital Status Children — Number Children — Ages Religion / Spiritual Practice If relevant Highest Level of Education Driver's Licence Code Current / Last Occupation Mobile Number Alternative Number Email Address Residential Address Prior to Admission Postal Address If different from residential

Responsible Person

What this role does. The Responsible Person pays fees, authorises leave, signs the Resident in and out, receives emergency communication, and may authorise additional visitors. This person must be contactable at all reasonable hours.

Full Names Relationship to Resident Identity Number Primary Contact Number Alternative Contact Number Email Address Occupation Employer Work Contact Number Residential Address Postal Address If different

Next of Kin & Emergency Contacts

Two contacts. The primary contact is the first person we call in an emergency if your Responsible Person is unreachable.

Primary Emergency Contact

Full Names Relationship Contact Number Email Address

Secondary Emergency Contact

Full Names Relationship Contact Number Email Address

Substance Use History

List every substance used in the past, regardless of when it was last used. Include alcohol, prescription medication misused, over-the-counter substances misused, and illegal substances. Honesty here keeps you safe.

Substance

Age First Used

Method

Frequency at Peak

Date Last Used

Currently Using?

Detoxification Completed? Where & When was Detoxification Completed? Previous Rehabilitation Programmes Name, location, dates Outcome of Previous Programmes History of Withdrawal Seizures, Delirium Tremens or Psychotic Episodes History of Overdose Dates and substances

Medical History

Tick any condition that has ever been diagnosed or treated, then provide the date and current status.

Allergies Food, medication, environmental — list all and indicate severity

Current Medication

Bring all current medication to admission. List every chronic, prescribed or routinely used medication, including natural remedies, homeopathic preparations, supplements and over-the-counter medication. Our appointed pharmacist will package your medication into weekly compliance packs.

Medication Name

Dose

Frequency

Prescriber

Reason for Use

Date Started

Mental Health History

Diagnosed Mental Health Conditions Previous Psychiatric Admissions Dates and facility Currently Under the Care of a Psychiatrist / Psychologist Name & contact History of Self-Harm or Suicide Attempts Current Thoughts of Self-Harm or Suicide

No Fleeting Regular With a plan

History of Hallucinations, Paranoia or Psychotic Symptoms History of Trauma That May Require Trauma Counselling History of Anxiety, Depression or Panic Attacks History of Eating Disorders

Legal History

Prior Criminal Convictions Pending Criminal Charges Currently on Bail, Parole or Correctional Supervision Protection Order in Force Against you, or in your favour Attorney / Legal Representative Attorney Contact Number Court Dates Within the Next 90 Days

Recovery & Programme Goals

Why this matters. Your goals shape your weekly programme. Be honest about what you want to achieve, what has worked before, and what hasn't.

Why are you seeking admission to Roots to Recovery at this time? Primary goals for the next three months What does long-term recovery look like for you? Triggers, people, places or situations to avoid Strengths and resources you bring to recovery Strategies that have helped you maintain sobriety before Strategies that have failed, and why Focus on employment readiness?

Yes Maybe Not now

Any other priorities to record

✓

Declarations & Signatures

Resident Declaration

I confirm the information recorded above is true, complete and accurate.
I understand that any false, misleading or incomplete disclosure may result in refusal of admission or termination of residence.
I authorise Roots to Recovery to verify the information disclosed, where reasonable to do so, and to use the information for the purposes of providing services to me.

Full Name Date I confirm — by ticking this box I consent electronically

Responsible Person Confirmation

I have read the information disclosed above.
To the best of my knowledge, the disclosures are accurate and I am not aware of any further matter that ought to have been disclosed but has not been.

Full Name Date I confirm — by ticking this box I consent electronically

Staff Confirmation

Admitting Staff Member Position Date Time I confirm — by ticking this box I consent electronically

Fill every required section, draw the resident signature, then submit.