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020 808 3758

Intake form

Personal data

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Date of birth

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Month

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Passport number

Passport expiry date

Important

Check your passport and see if it is valid for at least six months on departure. If this is not the case, you should apply for a new passport as soon as possible.

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Emergency contact

Full name

Relationship to client

Phone

Health insurance information

Health insurance company

Policy number

SSN/BSN number

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Person responsible for payment (private clients)

Name

Relationship to client

Phone

General practitioner / referrer details

Name

Relationship to client

Phone

Client's medical information

Type of addiction (substance/behavior)

For example: cocaine, gambling

Quantity

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Last visited treatment center (if applicable)

Date visited

Day

Month

Year

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Additional information

List existing medical condition(s):

If applicable, include other important medical data (e.g. medication use, food allergies, limitations, etc.):

Details of specific diet requirements (if applicable):

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Additional information you would like to share (optional)

GENERAL INFORMATION

Treatment

Cherrywood House is a treatment center that provides primary care to people who suffer from substance use disorders or have sensory/auditory processing problems. This means that our program is designed as a first intervention to: facilitate the first phase of the transition from active addiction to a healthy lifestyle; diagnose any psychiatric, neurological or psychological disorders that have contributed to the development of the addiction; and apply appropriate therapeutic treatment to enable the client to remain sober.

Depending on the nature of the addiction, it may be necessary for the client to undergo detoxification first to help the body get rid of the abused drug. Each detoxification that the client needs is carried out by nursing staff present 24 hours a day who are under the supervision of experienced doctors and other medical personnel in a partner institution.

The therapeutic guidance that clients receive at Cherrywood House consists of group and individual guidance sessions. Although the therapeutic approach is adjusted per individual, it is usually based on cognitive behavioral therapies. Clients also undergo a weekly session with a psychiatrist to monitor and treat any underlying disorders.

Cherrywood House runs a daily program. In addition to the therapeutic component, the planning and daily activities are aimed at supporting clients in the recovery of their physical, biological reserves through sleep, exercise, good nutrition and positive relaxation. The clients have to follow the house rules intended to maintain the therapeutic climate and to support them in restoring the necessary structure in their lives. You will receive a copy of the Cherrywood House Rules and Regulations.

Although Cherrywood House is proud to offer a clinically robust and evidence-based treatment program, the disorders we treat are complicated disorders influenced by a wide variety of factors that we have no control over. For this reason, Cherrywood House cannot make statements or guarantees about the outcome of the treatment of individual clients, although we will do everything we can to provide everyone with the tools to achieve a healthy and sober lifestyle.

Personal information distribution

Clients should be aware that information provided to Cherrywood House professional caregivers in the therapeutic context (individual and group sessions) will be shared within the multidisciplinary professional team to enable the best and most appropriate treatment. By signing this document, you consent to this distribution of your information.

Furthermore, in accordance with the South African Data Protection Act, 4 of 2013, we hereby inform you that your personal information (i.e. information you provide in connection with your medical history and communications made by you in the therapeutic context) will be stored on paper and in electronic form for a period of 10 years as required by law.

Cherrywood House will never use this information for any purpose other than those relating to your care and will ensure that all files relating to you are secured in accordance with legal requirements.

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Expulsion

Cherrywood House reserves the right to remove a client from the program in the event of multiple serious violations of the Cherrywood House Rules and Regulations in circumstances where a person's behavior is violent or otherwise seriously undermines the therapeutic climate or threatens the safety of other Cherrywood House clients.

If it becomes necessary to remove a client from the program, Cherrywood House will ensure that appropriate agreements are made about the client's departure in consultation with the emergency contact person and/or the referent mentioned on the Client's Intake document. In any case, the client must have left the house within 24 hours of removal. Cherrywood House does not grant a refund in the event of removal, but allows clients to return to Cherrywood House at a later date, after consultation and in agreement with Cherrywood House, for the remainder of the treatment not taken, in accordance with the Cherrywood House Readmission Policy.

Voluntary early dismissal

If a client leaves the treatment prematurely, Cherrywood House will not issue a refund. However, if a client decides to leave treatment within 72 hours of admission, 50% of the full treatment price will be refunded.

A Client who leaves treatment prematurely may not participate in the 12-month aftercare group meetings without the discretionary consent of the clinical team. This step is intended to ensure that the meetings of the aftercare group remain a positive and supportive environment for people who are making progress in their recovery.

Please also note that your discharge report shows the date of departure, which may affect the amounts payable by your insurance (if applicable).

Dealing with prescribed medication in case of early discharge

If a client goes out of treatment prematurely or is removed, Cherrywood House provides the client with the prescription medications for three days. We reserve the right to withhold the remainder of the prescribed medications for the client.

Psychiatric emergencies

If a client's psychiatric condition deteriorates to such an extent that more intensive care is necessary (i.e. the client poses a danger to himself or others), the client will be referred to an alternative facility in Cape Town (pre-screened and approved by Cherrywood House) and the costs of this care will be at the client's own account..

If a client's physical condition deteriorates to such an extent that admission to a hospital is necessary to ensure his safety, Cherrywood House will take all necessary measures to ensure that the client is admitted to the hospital. If a client refuses to be admitted to hospital in these circumstances, Cherrywood House will request the client to make arrangements to leave the institution.

Confidentiality

By signing this document, the Client commits to the strict confidentiality of all information he or she obtains as a result of staying at Cherrywood House to the extent that it relates to other clients, including the identity of these clients.

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I, {name-1} confirm that I have read and understood the information in this document and the Cherrywood House Rules and Regulations and I give permission for treatment at Cherrywood House on this basis. Furthermore, I do/do not give permission to pass on information about my treatment to my practitioner and/or the prescriber of my medications.

Sharing of information *I consentI do not consent

I further acknowledge that I am obliged to submit to the applicable laws and regulations during my transit to South Africa, as well as to the laws of the Republic of South Africa, and agree to indemnify Cherrywood House from any loss, liability or consequences of any kind that I may experience as a result of premature dismissal or flight from Cherrywood House.

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Signature *

Date *

Day

Month

Year

Please do not fill in this field.

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020 808 3758

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Nederlands kantoor, persoonlijke zorg en op feiten gebaseerde behandeling voor herstel van verslaving in Kaapstad, Zuid-Afrika.

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12 Cherry Lane, Belle Constantia, Kaapstad, 7806, Zuid-Afrika

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Singel 126,
1015 AE Amsterdam

info@cherrywoodhouse.nl 
020 808 3758

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