Apply for Smarmore Castle Admission - Secure Form

Filling in our secure online pre-admission form will help us to respond to your admission needs quickly.

Please note that this form helps us assess and determine your treatment needs in advance, but does not oblige you to treatment.

All information you submit will be treated as strictly confidential and will be sent and stored securely.

You need only complete as much as you can or feel able.  Once you are satisfied please click the submit button and we will respond to your submission as quickly as possible.

Prospective patient personal information
Person completing the form
Personal information

e.g. Parent, sibling, employer

Referral source
Alcohol / Drug Use
Primary substance used

e.g. Alcohol, cocaine, cannabis

e.g. Daily, weekly

Secondary substance used
Third substance used
Previous treatment
GP information

We will not contact your GP without your permission.

Social and Living Arrangements
Funding for treatment

EU cross-border funding sometimes requires you to pay upfront for treatment, and receive reimbursement later. Is this something you would be able to afford?

Health Insurance Information

Please include ALL Telephone numbers on your insurance ID card / recent correspondence from your insurance company:

Admission
Comments

Anything you haven't mentioned that might be helpful to know.

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