Pre-Admission Form | Road2Recovery

If there is any immediate risk to the person's safety today (a medical emergency, intoxication requiring urgent care, severe withdrawal, or thoughts of self-harm), please do not wait for a response to this form. Contact us immediately at +27 67 384 9624, or go to your nearest emergency room.

Don't fill this out:

Section A – About the Person Seeking Help

Full name

Date of birth

ID or passport number

Contact number

Email address

Physical address / suburb

Preferred language

Section B – About You (if completing this form on someone else's behalf)

Your full name

Your relationship to the person above

Contact number

Email address

Section C – Presenting Concern

What is most concerning you at the moment?

How long has this been a concern?

Is the person currently using, and when was the last use?

Has the person received treatment or counselling for this before? If yes, please describe briefly.

Has a medical professional been involved?

Section D – Health & Wellbeing Screening

Medical conditions or chronic medication taken

Ever experienced seizures, blackouts, or severe withdrawal symptoms when stopping use?

Mood or stress levels over the past two weeks

Support system at home (family, friends, community)

Section E – Practical Information

How did you hear about Road2Recovery?

Is the referral court-mandated?

Yes No

How will the care be covered?

Preferred format for sessions

In-person Online Either

Best day(s) and time(s) to reach you

Section F – Affordability & Fit Questionnaire

Please complete this brief questionnaire to help us understand your current financial alignment and determine the best service tier or payment structure for your goals.

Part 1: Service Tier Alignment

Select the service package or offering you are most interested in exploring:

Tier 1: Individual Coaching / Mentorship Sessions Tier 2: Group Wellness & Professional Development Workshops Tier 3: Comprehensive Corporate / Organizational Wellness Program Tier 4: Community Support & Resource Access

Part 2: Monthly Financial Snapshot

To ensure our pricing remains sustainable for your budget, please estimate your current monthly financial allocation:

What is your comfortable monthly budget range for professional wellness or support services?

Under R1,000 / month R1,000 – R3,500 / month R3,500 – R7,500 / month R7,500+ / month

How do you anticipate funding these services?

Self-funded (Personal budget) Employer-sponsored / Corporate Professional Development budget Grant-funded, Sponsorship, or Sliding-scale requirement

Part 3: Commitment & Investment Horizon

Our programs yield the best results with consistent engagement. Please select your preferred timeline:

Short-term intensive (1 month / Single project) Medium-term engagement (3 months) Long-term partnership (6+ months)

Part 4: Payment Structure Preferences

We offer flexible payment options to accommodate different financial workflows. Which structure works best for you?

Upfront Payment: Pay in full (eligible for a standard administrative discount) Monthly Installments: Automatic recurring monthly deductions Custom Plan: Requires a discussion regarding alternative arrangements or sliding-scale availability

Next Steps & Internal Review

Note: Once submitted, our team reviews your responses to match you with the most appropriate service tier or discuss flexible structuring if needed.

Consent

E-signature (type your full name)

Date

🔒 Everything you share here is 100% private and confidential, protected under POPIA, and only ever used to prepare for your assessment.

✓

Message sent.

Thank you. A member of our team will be in touch within 24 hours.