Questionnaire

Please Complete The Form Below For Home Detoxes

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Patient Information

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Name

Address

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Telephone Number

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Do you Skype, FaceTime or WhatsApp?

Date of Birth

Nominated Carer

The patient will be required to have a nominated carer, who is staying with them during the detox to supervise the treatment.

Name

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Permission to contact

Relationship

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Telephone Number

Medical Questions

Do you have a history of self-harm?

Do you have any suicidal thoughts?

Have you attempted suicide in the past?

Do you have any diagnosed mental health conditions?

Do you have a significant learning disability or cognitive impairment?

Are you attending any psychiatry services?*

Are you taking any medication?

Questionnaire

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

How often during the last year have you found you were not able to stop drinking once you have started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before, because you had been drinking?

Has a relative or friend, doctor or health worker been concerned about your drinking or suggested that you cut down?

Do you regularly drink between 15 and 30 units of alcohol per day?

Are you drinking over 30 units per day?

Pharmacy Telephone Number

GP Information

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Name

GP Address

Request A Callback

Receive a callback, we’re ready to help you get on the road to recovery.

24/7 Helpline Support

Don’t hesitate to reach out – we’re here to provide the support you deserve, anytime, day or night.

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