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  • Admission Form: By-Pass Highway, Moujuri Near Asansol Engineering College Jubilee Nh-2 Asansol 713323

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    Avishek Singh
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    This document is an admission form for a rehabilitation centre for drug addicts and alcoholics. It collects information such as the patient's age, marital status, qualifications, income, name, address, phone numbers, and relationship to the guardian. It notes the date of admission and time. It also lists terms and conditions for treatment including responsibilities if the patient leaves, compliance with drug laws, non-responsibility for accidents, and payment policies. The patient and guardian signatures are required at the bottom.

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    ALF Admission form

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    This document is an admission form for a rehabilitation centre for drug addicts and alcoholics. It collects information such as the patient's age, marital status, qualifications, income, name, address, phone numbers, and relationship to the guardian. It notes the date of admission and time. It also lists terms and conditions for treatment including responsibilities if the patient leaves, compliance with drug laws, non-responsibility for accidents, and payment policies. The patient and guardian signatures are required at the bottom.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    10 views1 page

    Admission Form: By-Pass Highway, Moujuri Near Asansol Engineering College Jubilee Nh-2 Asansol 713323

    Uploaded by

    Avishek Singh
    This document is an admission form for a rehabilitation centre for drug addicts and alcoholics. It collects information such as the patient's age, marital status, qualifications, income, name, address, phone numbers, and relationship to the guardian. It notes the date of admission and time. It also lists terms and conditions for treatment including responsibilities if the patient leaves, compliance with drug laws, non-responsibility for accidents, and payment policies. The patient and guardian signatures are required at the bottom.

    Copyright:

    © All Rights Reserved
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    Flag for inappropriate content
    of 1

    Rehabilita

    tion Centre for Drug Addict / Alcoholic


    Regd. Under W.B TRUST Registration Act Regd. No. IV – 230500041/2022/IV-41
    BY-PASS HIGHWAY, MOUJURI NEAR ASANSOL ENGINEERING COLLEGE JUBILEE NH-2 ASANSOL 713323

    Mobile number: 9732888697 | 9064989118 | 9749879073

    ADMISSION FORM

    AGE: …………………………………………………….… DATE OF ADMISSION: …………………………………………………………….

    MARATIAL STATUS: …………………………………………………………. TIME: ………………………………………………….……….

    QUALIFICATION: …………………………………………. OCCUPATION: …………………………………………………….…………….

    INCOME PER MONTH: ………………………………………………………………………………………………………………………………

    NAME OF PATIENT: ………………………………………………………………………………………………………….……………………….

    ADDDRESS…………………………………………………………………………………………………………………………………………………

    …………………………………………………………………………………………………………………………………………………………………..

    TELEPHONE NO: ………………………………. MOBILE NO: …………………………………………………………………………………

    RELATIONSHIP WITH THE GUARDIAN: ………………………………………………………………….…………………………………

    I am willingly keeping the above-mentioned person for treatment in Lakshya foundation Asansol for his
    unmanageable from (Alcohol/ drug addiction/ substance abuse any other).

    1. In case of any difficulty, the patient may/ may not be sent to home.
    2. The authorities will not be responsible if the patient leaves the Primeses of the faculty.
    3. We abide by the principles of narcotics and Phycotropic substance amendment bill (1988).
    4. In matter of accidents/ and/ or unusually behaviour, the authorities will not be responsible.
    5. The authorities will not be responsible for any valuables, clothes, ornaments or jewellery and the patient should not
    be provided with money inside the primises.
    Any sort of meeting with the patient is totally under the jurisdiction of the faculty authority.
    In case the patient leaves the primises without the consent of the authority, the remaining dues has to be paid by the
    patient’s family.
    Any kind of co-ersion or cession induction behaviour from the family or friends of the patient will result in immediate
    discharge of the patient whereby the outstanding dues should be paid by the patient/ family.

    SIGNATURE OF THE PATIENT SIGNATURE OF GUARDIAN

    DATE: …………………………. ADDRESS: ……………………………………………NAME: …………………………………

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