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AGAPE’ HOUSE
P.O Box 216, Greytown, 3250
+27 33 4172227
info@agapehouse.co.za
NPO 056442
PRE-ADMISSION / APPLICATION FORM
REFERRER TO COMPLETE
The referrer is also encouraged to assist the applicant in completing their own
application form.
INSTRUCTIONS TO COMPLETE THE APPLICATION FORM

The aims of the application form are:
1) To establish and improve the applicant’s motivation for treatment.
2) To obtain important information for treatment.
Please note that the completion of this form already confronts the patient
with his/her addiction problem and consequently forms part of the treatment.
Please attend to it carefully to benefit the patient.
FORM 1 (Completed by referrer)
SOCIAL WORKER/ PSYCHOLOGIST/ EAP OFFICER
(FORM 2 TO BE COMPLETED BY A MEDICAL PROFESSIONAL AND FORM 3 BY THE PATIENT)
IDENTIFYING PARTICULARS OF REFERRER: (PROFESSIONAL PERSON)
Name :_________________________________________________________
Occupation:_________________________________________________________
Organization: _________________________________________________________
Telephone No :________________________
Fax: _______________________
Email :_________________________________________________________
Town/City:_________________________________________
Code: __________
Postal Address:_________________________________________ Code: __________
Are you prepared to deliver after-care services? ___________________________________
FORM 2
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MEDICAL PRACTITIONER / PSYCHIATRIST TO COMPLETE
PLEASE NOTE THAT IF THE MEDICAL PRACTITIONER IS THE PRIMARY REFERRER, FORM
1 ALSO NEEDS TO BE COMPLETED, FORM 3 TO BE COMPLETED BY THE APPLICANT.
1.
Name of applicant: ______________________________Age: _____Height: ________Mass:_______
2.
Have you previously examined and treated the applicant? YES / NO
If so, when and for what reason? _______________________________________________________
3.
Has the applicant previously been hospitalized? YES / NO If so, where and what for?
___________________________________________________________________________________
4.
Is the applicant currently undergoing medical treatment? YES / NO
For what reason? ____________________________________________________________________
Current treatment? ___________________________________________________________________
In case of diabetes (insulin/oral medication) kindly do a HGT and provide meter. _________________
5.
Medical history (state date where possible):
Pulmonary Tuberculosis: YES / NO ___________
Treatment received: YES / NO ______________
TB Status at present: - Please attach report: _______________________________________________
Serious operations: YES / NO ________ Type: ____________________________________________
Serious accidents: YES/NO _______ Type: _______________________________________________
Epilepsy: YES/NO __________________________________________________________________
Allergy: YES/NO ____________________________________________________________________
Heart Disease: YES/NO _______________________________________________________________
Diabetes: YES/NO ___________________________________________________________________
Pancreatitis: YES/NO ________________________________________________________________
Liver Disease: YES/NO _______________________________________________________________
6.
Examinations:
B.P.: __________________________________
Abdomen: ______________________________
Heart: _________________________________
C.N.S: _________________________________
Pulse: _________________________________
Urine-test: ______________________________
Respiratory system: ______________________
7.
Nature of the applicant’s addiction problem: e.g. Alcohol/Tranquilizers/Patent medicines/Illegal
drugs.
What kind? ____________________________
When last used? __________________________
8.
Do you recommend that the applicant be admitted to Harmony Retreat? _________________________
9.
Is there any other medical condition for which the applicant should be referred to a hospital first?
______
10. Particulars of medical doctor: (please print)
Practice number: ________________________
Name: ______________________________Tel: ____________________________________
Address: _______________________________
Signature: ______________________________
_______________________________
Date: __________________________________
FORM 3
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PARTICULARS OF APPLICANT
Identification Number: ______________________________________________Age:__________________
Surname: __________________________________________________ Date of birth :_________________
Full Names: _____________________________________________________ Gender :_________________
Home Language: _________________________________________________________________________
Address: __________________________________________________________ Code_________________
Tel. Home: ______________________ Work: ____________________ Cell: _________________________
Marital Status: ________________________ Applicant’s skills:____________________________________
Is the applicant currently employed? __________________________________________________________
Briefly explain about the applicant’s recent employment history: ___________________________________
________________________________________________________________________________________
Church denomination: _____________________________________________________________________
Highest grade passed: _________ Tertiary qualifications:__________________________________________
Support base: Next of kin / Friend (preferably with whom the patient is staying) to be contacted in case of
emergency and early(self) discharge):
Name: __________________________________________________________________________________
Relationship: ____________________________________________________________________________
Tel: (H) __________________________ (W) ______________________ Cell: _______________________
Alternative emergency telephone numbers: _____________________________________________________
MEDICAL AID PARTICULARS
Name of Medical Aid: __________________________________ Plan/Scheme: ____________________
Full name and surname of main member: ______________________________________________________
Medical Aid no: ________________________________ ID number: ________________________________
Please phone your medical to obtain an authorization number before admission. They require the
following particulars:
Agape’ House registered as Harmony Retreat practice no:
054 8596
Physicians:
1.
Dr. T.A. Owen practice no:
147 5797
2.
Dr. Roodt
144 7637
Treatment codes:
Practice no:
Detoxification F10.2
Alcohol rehabilitation Z50.2
Drug rehabilitation Z50.3
Authorization no: _________________________________________________________________________
Tel. no of medical aid: _____________________________________________________________________
Postal address of medical aid: _______________________________________ Code: _________________
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PERSON / ORGANIZATION RESPONSIBLE FOR ACCOUNT
Organization/Company/Employer: _____________________________________________
Full name and surname: _____________________________________________________
ID number: _______________________________________________________________
Address: _________________________________________________________________
Code: ____________________________________________________________________
Tel: (H)___________________(W)__________________(C)_______________________
Acceptance of terms: (Complete relevant clause)
1. I, …………………………………………, accept that, if the treatment programme
of the patient, ……………………………………., is terminated prematurely, for
whatever reason, all monies will be forfeited.
2. In case of a medical fund I, ……………………………………., as main member of
the fund, accept full responsibility for the outstanding amount if the treatment
programme of the patient, …………………………………….., is terminated
prematurely, for whatever reason.
_______________
_____________
________________
________________
SIGNATURE
DATE
WITNESS
DATE
METHOD OF PAYMENT TO HARMONY RETREAT
Medical Aid: _____
Cash: _____
Cheque: _____
Bank Deposit ______
Bank details:
BANK:
NEDBANK GREYTOWN
BRANCH CODE:
134431
NAME:
The Agape House
ACCOUNT:
1105726894

Please use patient name and surname as reference on deposit slip.
FINANCIAL ARRANGEMENTS:
First month’s treatment fees (currently R15,000) must be deposited in Agape’ House account and proof of
payment to be forwarded to Harmony Retreat office before admission can take place. Any other arrangements
have to be approved and confirmed in writing by the financial director.
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A. ADDICTION PROBLEM
Please give the patient’s own answers to the next questions. False information may lead to discharge.
1.
What substance did you use? Specify ____________________________________________________
2.
How much did you use per day? ________________________________________________________
3.
Do you often have a craving for alcohol/drugs? ____________________________________________
4.
Do you use alcohol/drugs when you are worried/tense/or angry? _______________________________
5.
Do you have a craving to use more after the first drink/drug? __________________________________
6.
Are you currently drinking/using too much? _______________________________________________
7.
Do you often drink/use for a few days continuously? ________________________________________
8.
Do you feel shaky or sick in the morning after drinking/using the previous night? _________________
9.
Do you sometimes use alcohol/drugs in the morning (“regmaker”)? ____________________________
10. Do you sometimes have loss of memory? _________________________________________________
11. Have you considered drinking/using less? _________________________________________________
12. Does your drinking/use affect your family life negatively? ____________________________________
13. Does your drinking/use create problems at work? ___________________________________________
14. Does your drinking/use create financial problems? __________________________________________
15. Has your drinking/use caused deterioration in your health? ___________________________________
16. Have people pressurized you to go for treatment? ___________________________________________
17. Do you feel guilty about your drinking/drug use? ___________________________________________
18. Do you feel your substance use has become a serious problem? ________________________________
19. Who is responsible for your addiction? ___________________________________________________
20. For how long have you had an addiction problem? __________________________________________
21. Are you willing to, on a voluntary basis, do the full treatment at Harmony Retreat? ________________
B. PREVIOUS TREATMENT FOR ADDICTION PROBLEM IF ATTENDED
Please provide letters of confirmation from Treatment Centers/Clinics
CENTRE
ADMISSION
DATE
PERIOD
PROGRAMME
COMPLETED
YES/NO
PERIOD SOBER
AFTER
TREATMENT
C. JUDICIAL HISTORY
Did alcohol/drugs ever bring you into conflict with the law? _______________________
Are there any pending court cases against you? ______ Date of court case? _____________________
If charged with a criminal offence, please state what:__________________ Prison sentence?________
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Rules of Agape House
1.
No Drugs, alcohol or any other mood altering substance allowed on the premises. No drug talk is
allowed.
2.
Consumption of such substances is prohibited either on or off the premises.
3.
No profanity will be tolerated.
4.
Cell phones, cash, cash cards bankcards and/or medications are not allowed to be kept by residents.
These must be handed in on admission.
5.
Agape’ House’s vehicles are not to be driven by any resident without prior permission from
management.
6.
Smoking only allowed in designated areas at allocated times.
7.
No incoming calls during for first two weeks unless in emergency. No outgoing calls- unless in
emergency.
8.
No visitation during for first three weeks unless by prior arrangements. Only Family members and
those approved by them will be allowed to visit.
9.
Residents will not change rooms without prior permission, nor move items from one room to another.
10.
Residents will adhere punctually to the timetable regulating the Retreat activities.
11.
Male residents will not enter ladies accommodation and vice versa.
12.
Relationships of any nature, specifically sexual, physical and/or emotional involvement are prohibited.
Any romantic involvement will be dealt with severly and could lead to instant dismissal.

Random drug testing with be carried out regularly and the expense thereof to be paid by the patients

Please note that all new patients and their belongings will be searched on admission.
All
unacceptable items and inappropriate clothing items will be kept in storage until discharge.

A multi-Drug test will be conducted upon admission to determine substances abused.

Visitations are restricted to family members, and visitors are subjected to the procedure as set
out in our policy. Details will be given to sponsor/family on admission.
 Please note that Agape’ House is not a psychiatric clinic but a drug and
alcohol Treatment Centre. Should the patient deemed to have comorbidity (Dual Diagnosis) problems with a bias towards a psychiatric
issue, the management reserves the right to refuse admission and or
terminate treatment at any time.
 Agape’ House does not provide any detox facility or services. Should
the applicant been abusing Heroin, Sugars, Woonga or any other
opiate/Codeine based substances, they must undergo a detoxification at
a medical facility. Admission will take place once the detox treatment is
concluded. Alcohol abusers will be subjected to the same conditions, at
the discretion of the Agape House management,
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Disciplinary Procedures
A standard two warning system (verbal then written) is practised at Harmony Halfway House. A third offence
will result in a period of suspension.
However, the severity of the offence will determine the action required, and it will be in the discretion of
Harmony management
Declaration
I, __________________________________________ by my signature hereto:
a)
Give consent to Agape’ House to contact my personal physician and/or my
previous rehabilitation and/or Treatment Centers and/or any person that it may
deem necessary for any information pertaining to my previous treatments and
records, current treatment program or condition in order to assist Agape House
with my recovery.
b)
Acknowledge and understand that Agape House and its staff will not be held
responsible for any accidents, injuries, death and/or loss or damage to my
property while under their care.
c)
Acknowledge that I have read and accept all the rules and regulations governing
the Agape House and understand the consequences relating thereto.
d)
Consent to random urine/blood tests at the discretion of the governing body of
Agape House.
e)
Acknowledge that Agape House provides a multifaceted program and it may be
necessary at times for the multi-disciplinary team, including but not restricted to
permanent staff, volunteers, medical- and other professionals to discuss with and
disclose certain aspects of my recovery to each other, yet maintain confidentiality
within the said team.
f)
Understand that treatment fees are not refundable under any circumstances,
including voluntary and obligatory termination of treatment and/or discharge.
Signed at ___________________ on this _______ day of ________________20___
Signature by patient:____________________
Witness:______________________
Attention: Please ensure that the applicant reads the rules and expectations of Agape’ House and understands
them.
Agape’ House will not admit any patient before this application having been processed and approved by the
multi-disciplinary team.
Applicant’s Signature:__________________________________ Id. Number
declare that I have read the form carefully and I understood it.
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