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Questionnaire

Complete this questionnaire to receive initial private treatment centre recommendations. If you would rather discuss your treatment options in person please call us on 0845 603 6530 or use our contact form.

The questionnaire can be a useful first step in determining appropriate private treatment centres for your alcohol and/or drug addiction. Selecting a private residential rehab centre or detox clinic should not be done lightly; you should have as much information as possible. To determine the best one for you, Re-cover strongly advises a follow-up phone conversation.

Your name:
Your are the:
patient
acting on behalf of the patient
Your email:
Your phone number:
Name of the client (if applicable:)
Age:
Sex:
male
female
Location: Town Country Postcode
Addiction or problems: alcohol cocaine heroin painkillers
    other 
Drinking/using: daily 5 times a week 3 times a week once a week
What and how much
If the problem is alcohol do you suffer from:
blackouts (i.e. memory loss)
night sweats
body tremors
hand shakes
mood swings
depression
aggressive behavior
How long has the problem existed:
weeks months 6 months+ 12 months+ 2 years+
Do you live with your partner :
yes no
Does this addiction negatively effect:
personal life
career
Please explain in more detail
Is the client currently working? yes no
Does the client have private health insurance? yes no
Has the client been in treatment before? yes no
If Yes, which centres
How long could the client be away from home in order to successfully treat your addiction:
must be treated at home
1 to 2 weeks
4 weeks
6 weeks
12 weeks
International treatment options acceptable? yes no
Available level of funding:
Don’t know
Less than £4000
£4000 to £8,000
£8,000 to £12,000
£12,000 to £16,000
£16,000 or over
Rather not say
How would you like to receive recommendations?
by phone from Re-cover
by phone directly from the centres
no contact at this moment
by email from Re-cover
by email directly from the centres
send
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