Application Form for Livingstone House

L

ivingstone

H

ouse

It would be helpful if you would fill this form in as clearly and completely as possible.

All information on this form will be treated in a secure and confidential manner in accordance with the Data Protection Act 1998

Feel free to telephone the Admissions Department at Livingstone House if you have any queries or need some advice, and we will do our best to help.

The more accurately and completely you fill in this form, the sooner your application can be processed.

Please return this form to the address below. Thank you.

Learning to live with self, with hope and achieving freedom RESIDENTIAL TREATMENT AFTERCARE DETOXIFICATION FIRST STAGE PRIMARY SECONDARY CARE RE-ENTRY LIFE SKILLS SPIRITUAL GUIDANCE WORKING RECOVERY FAMILIES CODEPENDENCY ISSUES COMPREHENSIVE PHYSICAL MENTAL AND SPIRITUAL CARE Head Office : Livingstone House, 290 Mansel Road, Small Heath, Birmingham, B10 9NN Tel & Fax : 0121 753 4448 Mobile : 07787 515494 Email : [email protected]

Charity Comm Reg No : 1102286

Basic Information About You

Full Name : Date of Birth : If you would prefer to be known by another first name, what is it ?

Sex: M/F Current Address : Daytime telephone: Nationality: Post Code : Email: Ethnic origin: Four auditing purposes, we are asked by Health Authorities to record the ethnic origin of those we treat. The categories are those used in the UK census. We would be grateful if you would circle the category that describes you best.

White British White & Black Caribbean Black Caribbean/Black Caribbean British Indian/Indian British Black Caribbean White Irish White & Black African Pakistani Black African/African British Other White White and Asian Bangladeshi Other Black/British Other Mixed Other Ethnic Other Asian/Asian British Chinese

Currently are you single ?

Or in a partnership or marriage relationship ?

How many children (including step children) do you have ?

How many are under 18 and directly dependent on you ?

How many are currently living with you ?

Are you currently : employed/unemployed/student/full time home maker If working, what is your occupation or business ?

If unemployed, how long have you been so ?

What was you main occupation in the past ?

What is your GPs name, address and telephone number ?

Which Local Authority area do you live in ?

If you have a Care Manager, what is his/her name, address and telephone number ?

Have you ever had a Community Care Assessment ?

YES/NO

PLEASE SIGN THIS AUTHORITY FOR RELEASE OF INFORMATION TO ENABLE THIS APPLICATION TO PROCEED

I hereby give permission for all care professionals with whom I have been involved to release to Livingstone House any relevant information which may be required.

Livingstone House may release to my Local/Health Authority such details as may be required to apply for funding.

On my discharge I accept that reports may be sent to all care professionals involved in my care to support my continuing recovery.

Please sign here : Print name : Date :

About Your Problem

What is your main problem substance ? (eg : alcohol, heroin) Has your main substance changed ? (eg: I used to have a heroin problem, now I have an alcohol problem). Please describe : Would you consider yourself to be an addict ?

Would you consider yourself to be an alcoholic ?

How old were you when you started to drink alcohol ?

How old were you when you started to use drugs ?

For the following section, please tick drug that isn’t mentioned (eg : ecstasy, hallucinogens, solvents or steroids) please name these under “Other”.

all

the boxes that apply to you. If you regularly use any Alcohol Opiates (heroin, methadone) Cocaine/crack Cannabis Amphetamines Tranquillisers Sedatives Prescribed medication Other I use this I have problems connected to my use of this I feel I use this too much or too often I feel I use this too much or too often I use this much I use it this I have used it for.. often (how long)

More About You

What are the most important life problems that you are facing that are connected to you alcohol or drug problem ?

Are you currently receiving counselling or medical help with your problem ? Please describe Have you been through a treatment programme or course before ? Please describe Have you attended self-help groups such as Alcoholics Anonymous or Narcotics Anonymous (AA/NA) ?

Did you attend regularly and do you find this kind of support helpful ?

Why do you want to come to Livingstone House ?

Why do you want to stop drinking or using ?

What do you know about the treatment process ?

Our treatment is aimed at a recovery based on abstinence from all drugs and alcohol

How do you feel about this ?

About Your Medical History

So that we can help you come off drugs or alcohol as safely and as comfortably as possible, there are certain things that our General Practitioner/Mental Health Nurse needs to know. Answering “yes” to any of the following questions does not mean that you will not be accepted for admission. We need as much relevant information as possible to ensure that your treatment is safe and successful.

Please list your current prescribed medications : Are you currently under any kind of medical care ? If yes, please give details : Yes Have you ever been admitted to hospital ? If yes, why ?

Yes Have you ever been treated for a psychiatric illness? If yes, why ?

Yes Have you ever attempted to harm yourself ? If yes, please let us know when and how : Yes Have you ever had an eating disorder ? If yes, is this currently active ?

Yes Have you any painful conditions ? If yes, please give details : Yes Do you have mobility problems ? (eg: walking etc) If yes, please give details : Yes No No No No No No No Do you have any infections that may be contagious? If yes, please give details : Yes No Are you waiting for any medical investigations, procedures or appointments ? If yes, please give details : Yes No

If you are currently being treated for a psychiatric or blood borne virus related illness, please give details about the specialist and return it with the application form. Thank You

About Your Current Legal Situation

Do you have a Probation Officer ?

If Yes, please give his/her and contact details : Yes No Do you have any outstanding legal issues ?

If Yes, are you : Yes On bail ?

On probation ?

On parole ?

On a suspended sentence ?

On a deferred sentence ?

On a DTTO (drug testing and treatment order) ?

On a condition of residence ?

Awaiting charges ?

Awaiting Trial ?

Awaiting Sentencing ?

In there is anything else you would like use to know, please write it here : No

How Will Your Treatment Be Paid For ?

Please indicate which of the following applies to you

I will be paying for my own treatment My family will be paying for my treatment I will be contributing toward my treatment from my benefits I have private medical insurance

Please indicate with whom :

BUPA PPP Royal and Sun Alliance CIGNA Other My employer will be paying for my treatment

Please give your employer’s details and a contact name :

My Probation Officer is arranging to pay for my treatment My Care Manager is arranging to pay for my treatment

If you need assistance to obtain funding for your treatment and have not yet contacted Social Services, please contact the Admissions Department at Livingstone House (0121 753 4448) and the staff there will do their best to advise you on how to proceed. Please feel free to contact this department during office hours for help or advice about your admission to treatment.