Please complete this form IN FULL, with a copy of your assessment and if possible the following information in order to expedite our assessment and admission process.

  1. GP Medical summary to include any medical problems, any medications that are being taken, any psychiatric history
  2. Liver Function Tests and INR Tests are needed for all alcoholic and cross addict referrals
  3. A psychiatric report is there is any psychiatric history
  4. Criminal Justice: Details of Probation contacts, conditions and if applicable a pre-sentence report and details of previous convictions
  5. If prescribed Methadone, Subutex or Benzodiazepines as part of an existing treatment programme a copy of the current dosing and reduction regime

It is important that the patient signs the 'Release of Information' section at the bottom of this page. This gives consent for Broadway to obtain information from the GP and any other professionals s/he is working with especially if the information above is not available.

If the application form is incomplete or there is insufficient detail provided, we will contact you in order to obtain further information. Please note that this may delay the assessment and admission dates offered.

Confidentiality

All information received will be treated confidentially.

Queries

If you wish to speak to the Admissions Department for clarification on any point, please call on 01934 815515.


Treatment Application Form

Release of information

I give consent to Broadway Lodge to obtain information from my GP and any other professionals with whom I have been involved.

I agree that there will be letters and discharge reports sent to those professionals involved with my care.

You will need to notify your GP and other professionals that we will be requesting information from them and you will need to give them your permission for this to be released.


General Information



Your GP





Alcohol & Drugs Information

Some of the questions in this section may not be relevant if you are applying for Secondary Care.


Hepatitis B


Hepatitis C


HIV



Medical Information


Legal


Exit Plan


Data Reporting

For NDTMS reporting purposes, please indicate the current intention after leaving Broadway Lodge:


Other Information

Please see our Privacy Policy.