Admissions - New Hope Rehab Bali - Addiction Rehab in Bali

Admissions Form

I hereby authorize NewHope Rehab Bali and its staff to review and use the information provided in this admissions form for the purpose of assessment, treatment planning, and healthcare services. I understand that my personal information will be kept confidential in accordance with applicable laws and regulations.

Request Submission Form

Please Choose the Service You Want

FREE 30-MINUTE CONSULTATION SESSION

REGULER APPOINTMENT

Choose Our Programs

FULL NAME

DATE OF BIRTH

PHONE/MOBILE

EMAIL ADDRESS

ADDRESS

STATE

CITY

COUNTRY

TYPE OFF ADDICTION

AMMOUNT USED AND FREQUENCY

ARE YOU ON PRESCRIPTION DRUGS?

CURRENT DOCTORS INFORMATION

PLEASE TICK IF APPLICABLE

	Please Select
Do you require Detox?
Any history of self -harm/suicide/arson?
Are you currently on probation
Do you have any outstanding warrants?

IF YOU TICKED A BOX PLEASE ADD MORE INFO HERE

reCaptcha