REFERAL AND APPLICATION FORM -
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1 NAMAQUA TREATMENT CENTRE REFERAL AND APPLICATION FORM - This completed form must be faxed to Namaqua Treatment Centre at without delay. Please complete this form in full in conjunction with your Medical doctor in order to be admitted to our treatment centre. Because of the fact that this form needs to be completed with your doctor s assistance, be sure to make an appointment with him/her to do so. Should your own doctor be unavailable or you prefer to be seen by our doctors, please notify us that we can arrange for one of our local doctors to assist you with the completion of this form. Although we will use every endeavor to recover your related expenses from the Medical aid. The account remains your responsibility. If you receive a Medical aid authorization number, the Medical aid agree upon payment of their contracted fees Our tariff is R32500 for 21 days For Payment queries, Medical aid Authorization or admittance inquiries, contact: Mrs. Ina Jooste of Namaqua Treatment Centre (NTC): Tel: fax: , info@namaqua-rehab.co.za. Note: above mentioned rates cover the Inpatient treatment programme fees only. Any professional inputs/consultations (e.g. with Doctor, Psychologist, Psychiatrist, etc) will be for the patients own account. (This should be recouped from the hospital portion of your Medical aid, please contact your Medical aid in this regard.)
2 1. GENERAL INFORMATION: Personal Information: Full Name:... Date of birth:.. /.../..... Address:..... (Home)... Address: (Postal)..... Next of kin: (please supply us with the detail of 2 close relatives/acquaintances) Id. number:..... Passport no... if non-rsa resident) Country of residence:... if non-rsa resident) Tel. no: home:( )... work:(..)..... cell: Name: Contact no: Name: Contact no: PAYMENT *( For account enquiries: Mrs. Ina Jooste: tel: fax: , info@namaqua-rehab.co.za) TE: If you are not a member of a Medical aid, procedures are not covered, and/ or funds are depleted, the method of payment is STRICTLY CASH. To be completed in every instance : Supply the detail of the person/company responsible for payment: Indicate with X: Self / Sponsor: Full Names:.... Relationship to patient:... Telephone no: Bank detail for internet transfer/deposit: Branch: FNB Somerset West Account No: Branch No: *Please fax proof of such pmt through to Medical aid detail: (complete in addition ) Name of Medical aid:.... Plan type/name:... Member no: Entry date: Detail of Main member: Full Names: Address: Tel. No: ( ). Does this Medical aid make provision for addiction rehab? Yes No
3 3. -SCREENING BEFORE ADMISSION: If you reply Yes to any of the following questions, our treatment centre cannot admit you and we will assist you in an alternative referral to another treatment centre: MARK WITH X I am legally referred, awaiting legal action/trial: YES I am not yet 18 years old: YES I have no financial support and need free treatment: YES I feel forced to attend the treatment programme and I am going to be very resistant and troublesome during treatment: YES 4 SUBSTANCE HISTORY: Have you ever used any of the following other than for treatment of a medical condition under proper supervision of your doctor? 4.1 Amphetamines, e.g. Estacy, Ice, MDMA, Speed, Upper, Appetite suppressors, etc. YES 4.2 Methaphetamine Tik, Meths, etc. YES 4.3 Dagga (Cannabis), e.g. Hashish, Marijuana, Pot, Weed, etc. YES 4.4 Cocaine, e.g. Coke, Crack, Snow, etc YES 4.5 Hallicinogens, e.g. Acid, Angel dust, Haze, LSD, etc. YES 4.6 Mandrax (Methaqualone), e.g. Whites, Buttons, bandits etc. YES 4.7 Opiates, e.g. Codeine, Heroin, Methadone, Morphine, Opium, Smack, Cough remedies, etc. YES 4.8 Sedatives e.g. Diazepam, Downers, Nitrazepam, Tranks, tranquilisers, sleeping tablets, etc YES 4.9 Solvents, e.g. glue, aerosols, etc. YES 4.10 Alcohol YES 4.11 Did you use any of the above together with prescribed medication? YES 4.12 Other YES If yes to any of the above, the following additional information is required: What type of drugs/alcohol did you use?.... The date on which you started to use the drugs/alcohol?
4 . The last date on which you have used the drugs/alcohol?..... How many times did or do you use drugs/alcohol per month?. Have you ever been involved in violent acts of did you ever transgress any of the laws of the country or clash with the police or violated conditions of an interdict against you? (state all the relevant detail).... PREVIOUS INTERVENTIONS: Have you attended any other rehabilitation programmes in the past? YES If YES, indicate: Name of rehab?.. Dates of admission:.... Personal experience with the rehab programme: Reason for relapse?. 5 MEDICAL HISTORY: 5.1 Personal medical history: Mark with X if YES, give full detail in each instance: Birth process/problems: YES Developmental problems: YES Child illnesses: YES.... History of epilepsy: YES Seizures: YES
5 Attention Deficit Disorder with or without hyperactivity: YES. Psychological problems: YES. Adjustment problems: YES. Social adjustment problems: YES. Accidents/injuries: YES.. Operations: YES... Psychiatric consultations: YES. Aggressive behaviour: YES.... Suicidal thoughts/attempts: YES.... Other relevant medical history not mentioned above: YES Current medical conditions: (E.g. diabetes, high blood pressure, heart problems, asthma, epilepsy, psychiatric/psychological problems). 5.3 Medication currently on: (The official/original doctors prescription needs to accompany the patient in order to be able to continue with such medication during treatment) Prescribed Medication: Medical/Psychiatric Conditions:
6 5.4 Risk Assessment: Please answer YES/ to the following. (MARK WITH AN X) Do you feel socially isolated? YES Do you feel out of control on the substance YES (a lower sense of self-control) Do you have any psychiatric/psychological problems e.g. depression, anxiety, bipolar disorder etc? YES Do you have a chronic medical illness that worries you a lot? YES Any previous suicide attempts? YES Did you lose something (relationship, money, job, child, loved one)? YES Do you experience feelings of hopelessness? YES Has life lost its meaning for you? YES Do you hear voices in your head that tell you to harm yourself? YES 6. DOCTOR S CLINICAL FINDINGS (as at examination) 6.1 Complaints (Reason why help is needed at this stage) Illnesses (Medical/surgical, current medication) Previous history of psychiatric illnesses: (diagnosis, treatment and hospitalization) Family illnesses (Psychiatric and other) 6.5 Substance history: Is the patient addicted to a chemical substance, or does he use the substance to cope - possibly resulting in addiction in the future?....
7 Does the patient have a substance dependency? YES Does the patient use the substance to cope with a co-morbid psychological/psychiatric condition, and is not yet addicted to the substance? YES If YES, Please motivate: Has the patient now, for a lengthy period, been on prescribed medication (not substance) due to a psychological/psychiatric condition, which resulted, however, in a need of intense psychological therapy to overcome the problem? YES 6.6 Detoxification: NB: All Alcohol, Opiates and Benzodiazepine dependency should first be detoxified.(as stipulated by the protocol of in-patient treatment) Is there a need for detoxification? YES. Who needs to take care of the detoxification process? (In case of patients from afar, our local doctors prefer to do the detoxification at Vredendal Hospital as they are responsible for the patient whilst in treatment at NTC. However, should the patient be in a crisis, detoxification could be done elsewhere and then referred to our Centre.) - the referring doctor:. Location: the treating doctor: (At Vredendal Hospital) 7 CLINICAL IMPRESSION (as at examination) Appearance and behaviour:.... Level of consciousness:. Orientation (person, place and time).... Attention level:.. Mood disturbance.. Affective impression:.. Suicidal risks:.. Previous attempts at suicide:. Thought processes:
8 Perceptions (hallucinations):.. Memory: impairment:. Delusions:. Level of intelligence:... Acceptance of substance addictive problem:. Sleeping patterns: Eating patterns:... Energy levels:.. Sex drive: PROVISIONAL PSYCHIATRIC DIAGSIS Provisional until verified by psychiatrist, Please indicate the ICD10 codes as required by the Medical aids for authorization, where needed Axis 1 Psychiatric diagnosis : DSM IV and ICD 10 codes are essential... Axis 1 Differential diagnosis on Axis 1Psychiatric diagnosis : DSM IV and ICD 10 codes are essential :.... Axis 2 Personality factors, development deficiencies:.. Axis 3 Medical conditions:. Axis 4 Psycho-social stressors:.....
9 Axis 5 Level of personal function: ANY RECOMMENDATIONS: General: Will you recommend that his/her family, spouse or caregiver needs to be involved in the treatment programmes, and why do you recommend that?..... Do you need to get feedback from the centre on progress and prognosis?... /
10 10. AUTHORIZATION: TE: For Medical aid Authorization, contact: Mrs. Ina Jooste of Namaqua Treatment Centre(NTC): Tel: fax: , The referring doctor/psychiatrist will provide NTC with treatment codes needed for admittance authorization-, which is the reason why you need to consult with your doctor/psychiatrist-. The Medical aid requires the following particulars: (Phone the N.T.C to obtain relevant information in all cases) (Please provide where applicable Name of institution: Physician: Psychologist: Psychiatrist: Other :. Namaqua Treatment Centre... practice no: 047/001/ practice no:. practice no:. practice no:... practice no:.... practice no:... practice no:.... Treatment codes (ICD10) Detoxification: Alcohol rehabilitation: (In-patient treatment) Drug rehabilitation: (In-patient treatment) Co-morbit psychiatric conditions: Other:.: Medical aid : Authorization No: Tel nr: Fax nr: Postal Address: ( ). ( )....
11 Detail of Medical Doctor/Psychiatrist: Name: Occupation: Telephone no: address Street address: Signature: code: Practice no: Organization: Fax no: Postal address: Date code: DECLARATION OF PATIENT: - I declare and guarantee that the above mentioned information is true, complete and precise. - I agree that I hereby give my full co-operation and accept my responsibility in the process of recovery Signed at: Signature: Date: MEDICAL TE: The programme that we will follow at Namaqua Treatment Centre is based on Psychiatric/Medical and Psychological therapeutic approaches, where proper assessment of the underlying emotional problem (why the need for the substance exists) will be done by a multi-disciplinary team (psychiatrist, doctors, psychiatric nurse, psychologist, addiction counselors). We follow an eclectic approach (using different therapeutic and alternative models) to focus on the whole person
NAMAQUA TREATMENT CENTRE "one more bridge to cross... for a better life"
- REFERAL AND APPLICATION FORM - This completed form must be faxed to Namaqua Treatment Centre at 086 685 8314 without delay. Please complete this form in full in conjunction with your Medical doctor in
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