SURNAME:

FIRST NAME:

OTHER NAMES:

DATE OF BIRTH:

SEX (Tick as appropriate):
MALEFEMALE

MARITAL STATUS:
SINGLEMARRIEDDIVORCEDWIDOW

AGE:
15 - 20 YRS21 – 30 YRS31- 40 YRS41- 50 YRS51 – 60 YRSABOVE 60

RELIGION:
CHRISTIANITYISLAMOTHERS

NATIONALITY:

CONTACT ADDRESS:

GSM NO:

OTHER NO(s):

EMAIL ADDRESS:

DATE (or MONTH) OF FIRST CONTACT WITH CADAM:

POINT OF CONTACT WITH CADAM (LOCATION):

SUBSTANCES FOR WHICH YOU SEEK REHABLITATION (list them):

DATE OF FIRST INTERVIEW WITH CADAM:

DATE ENROLLED INTO CADAM HOUSE:
[data dateOfEnrollment]

WHICH CADAM HOUSE ARE YOU IN?:

FAMILY BACKGROUND:
FATHER

NAME:

GSM NO:

OCCUPATION:

OFFICE/CONTACT ADDRESS

MOTHER

NAME:

GSM NO:
[te* mGSM]

OCCUPATION:

OFFICE/CONTACT ADDRESS:

TYPE OF FAMILY UNIT:
MONOGAMOUSPOLYGAMOUSDOTHER (specify)

NO OF SIBLINGS:

POSITION IN THE FAMILY:

NEXT OF KIN:

N.O.K.’s GSM N0:

ADDRESS OF NEXT OF KIN:

IN ANY CASE OF EMERGENCY, PLEASE CALL (FULL NAME, ADDRESS & PHONE NO), if different from the above:

SUSTANCE ABUSE HISTORY

YEAR ABUSE STARTED:

HOW DID YOU GET INTRODUCED TO DRUGS:

PAST ADDICTION TREATMENT(S) AND DATES:

HAVE YOU BEEN TO CADAM BEFORE:

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