Pre-admission - Rehabilitation Centre in Bloemfontein

MeziTouch Rehab: Addiction Self-Assessment Form

Pre-admission Form

Name

First Name

Last Name

ID Number

What substance or addiction are you currently struggling with? (e.g., alcohol, cannabis, cocaine, gambling)

How long have you been struggling with this addiction?

Do you feel your drug, alcohol, or addictive behavior is causing problems in your life?

Are you interested in stopping or reducing your substance use or addictive behavior?

Have you tried to quit before?

If yes, what happened?

When was the last time you used the substance or engaged in the behavior?

Have you experienced withdrawal symptoms or strong cravings when trying to stop?

Do you have any medical or mental health concerns we should know about?

Do you have support from family or friends for treatment?

Are you willing to participate fully in a rehabilitation program?

What are your goals for recovery?

If you are human, leave this field blank.