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Apply Online - Noupoort

Please Fill in the Form Below to Apply for Admission at Noupoort Christian Care Centre

(This Information will be Automatically be Delivered to the Program Manager and the Admission Department)

Apply Online - All Residents

Last Name *

First Name *

Date of Birth *

ID Number of Resident *

Age *

Gender (Choose) *

Marital Status *

Dependants *

Please Provide a Bit of Background on the Patient *

Church Affiliation

Pastor's Name

Pastor's Contact Number

Who Referred you to Noupoort? *

Referrer's Contact Number

Why Noupoort? *

Home Address *

Home Language *

Contact Email 1 *

Contact Email 2

Mobile Number *

Home Number *

Work Number

Other Number

Qualifications

Profession

Hobbies

Position

Years Employed

Court Case Pending - Please List Them *

Sponsor Surname *

Sponsor Name *

Sponsor Relationship *

Sponsor Physical Address *

Sponsor Language

Sponsor Postal Address

Sponsor Email *

Sponsor Mobile Phone *

Sponsor Home Number

Sponsor Other Number

Family Details - Next of Kin *

Relationship to Next of Kin *

Mobile Phone *

Home Phone *

Email *

Work / Other

Main Drug of Choice *

Alcohol

Mandrax (Buttons)

Tik / Meth

Heroin

Dagga

Khat

Crack

Ecstacy

Meds

Cocaine

LSD

Solvents

Other Drugs Tried

Alcohol

Mandrax (Buttons)

Tik / Meth

Heroin

Dagga

Khat

Crack

Ecstacy

Meds

Cocaine

LSD

Solvents

Specify Other Drugs, Addictions or Problems

Previous Rehabs Attended *

Physical Condition *

Comments

Are you on prescription meds? *

...if 'Yes', please Explain:

Period on Medication

Note Regarding Meds

Psychiatrist / GP who prescribed the above Medication

Are you presently under medical treatment If yes, reason and treatment *

THE ABOVE QUESTION AND BELOW SECTION ARE TO BE COMPLETED TO PREVENT THE APPLICANT FROM FABRICATING AILMENTS TO PREVENT THEM FROM GETTING INVOLVED IN THE PROGRAM.

...if yes, state reason and treatment

Time on Treatment

Note on the above

Have you been tested for any of the below? *

AIDS

TB

Syphilis

Hepatitis

Any other tests?

I agree to be tested for the above while in Noupoort *

MEDICAL HISTORY / INFORMATION *

Serious operations

Serious illnesses

Serious injuries

Self mutilation

Anorexia

Bulimia

Notes

Any Allergies or Asthma *

Any other information with respect to applicant’s physical condition

Are you on a Disability Grant? *

If yes, explain...

Is the applicant on medical aid (if so please provide details)

I hereby acknowledge that all information provided in this application is honest. *

I have read the rules and the attached daily routine and bind myself thereto. *

I agree to have tests done at any given time for drugs and/or alcohol. *

I agree to be tested for AIDS, TB, Syphilis and Hepatitis. *

I understand that should I decide to leave the program before the completion date that NCCC is not obliged to assist me in any way. *

I understand that I will forfeit all funds should I leave the program before the completion date. *

I understand that relapse is not part of NCCC program and the use of any addictive substance during my program at N.C.C.C will result in a new program. *

Should a resident abscond the sponsor/parent must return her/him before 48 hours lapses to ensure continuing the program. *

My Name *

Today's Date *

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Noupoort Christian Care Centre - Drug Alcohol Addiction Behaviour Rehab

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