Title / Titlu:
--- Mrs/Doamna Ms/Domnisoara Mr/Domnul Dr Prof Rvd Sir Lord Lady Hon
Full name/ Nume si Prenume*:
Email address/ Adresa de e-mail*:
Home phone/ Telefon acasa:
Mobile phone/ Telefon mobil*:
Home address/ Adresa de resedinta:
City/ Oras*:
Zip / Postcode / Cod postal:
Country / Tara*:
--- Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic (CAR) Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (Swaziland) Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea North Macedonia(Macedonia) Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates (UAE) United Kingdom (UK) United States of America Uruguay Uzbekistan Vanuatu Vatican City (Holy See) Venezuela Vietnam Yemen Zambia Zimbabwe
Date of Birth/ Data nasterii:
Sex:
--- Female Male
Present marital status/ Stare civila:
--- Single/ Celibatar Married/ Casatorit Divorced/ Divortat Widowed/ Vaduv
Occupation/ Profesia:
Details of any dependents/ Detalii despre persoanele apropiate:
Living arrangements/ Cum locuiti:
Emergency contact / next of kin / Contact de urgenta / Ruda apropiata
Full Name/ Nume si Prenume:
Relationship to prospective patient/ Relatia cu pacientul:
Awareness of drink / drug problems? Stiti despre problemele lor cu drogurile/ alcoolul?
--- yes/da no/nu
Home phone/ Telefon acasa:
Mobile phone/ Telefon mobil:
Home address/ Adresa de resedinta:
City/ Oras:
Zip / Postcode / Cod postal:
Country/ Tara:
--- Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic (CAR) Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (Swaziland) Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea North Macedonia(Macedonia) Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates (UAE) United Kingdom (UK) United States of America Uruguay Uzbekistan Vanuatu Vatican City (Holy See) Venezuela Vietnam Yemen Zambia Zimbabwe
Person completing the form/ Persoana care completeaza formularul
Is this form being completed as part of a family / employer intervention? / Este formularul acesta completat de catre familie, angajator/coleg de lucru?
--- yes/da no/nu
Referral source/ Surse de recomandare
How did you first hear about Castle Craig?/ Cum ati aflat de Castle Craig?
--- Your doctor/ De la doctorul de familie Web Search/ Cautare web Family member / friend / Membru al familiei/ prieten Advertisement/ Reclama Phone directory/ Cartea de telefoane Social networking/ Retele sociale News story/ Articol din presa Other (please specify)/ Altele (va rugam pecificati)
What encouraged you to make contact with Castle Craig?/ Ce v-a incurajat sa contactati Castle Craig?
Details of any doctors / therapists / family member or friend who referred you to Castle Craig / Detalii despre doctori/ terapeuti/ membri ai familiei sau prieteni care v-au recomandat Castle Craig:
Alcohol / Drug Use / Consumul de droguri/ alcool
How many substances are being used (alcohol, drugs, etc)? / Cate substante consumati (alcool, droguri, etc)?
--- 1 2 3 or more/ sau mai multe
Details
Previous treatment/ Tratamente anterioare:
Further info/ Informatii suplimentare:
GP / doctor information/ Informatii despre doctorul de familie
Name/ Numele doctorului dvs de familie:
Telephone/ Telefon:
Home address/ Adresa de resedinta:
City/ Oras:
Zip / Postcode / Cod postal:
Country/ Tara:
--- Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic (CAR) Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (Swaziland) Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea North Macedonia(Macedonia) Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates (UAE) United Kingdom (UK) United States of America Uruguay Uzbekistan Vanuatu Vatican City (Holy See) Venezuela Vietnam Yemen Zambia Zimbabwe
Funding for treatment
--- Self/ Eu/ Familia Private Health Insurance/ Asigurare de sanatate privata Employer/ Angajatorul Other (please specify)/ Alte persoane (va rugam specificati)
Admission/ Internare
Availability for admission/ Disponibilitatea de internare:
--- Immediate/ Imediat Future date/ Ulterior Undecided/ Indecis
Comments/ Comentarii