Serenity Rehab Admissions Form

This Admissions Form is the second step in the Serenity admissions process

  1. Review the admissions requirements (below)
  2. Submit the Serenity Rehab Admissions Form (this page)
  3. Discuss the admissions request with Serenity's Managing Director
  4. Upon approval, set arrival date and addiction treatment length
  5. Make deposit or full payment
  6. Make flight reservations to Serenity Rehab in Chiang Rai
  7. Travel to Serenity Rehab to begin the treatment programme

Rehab Admissions Form

*Required

Contact Information

First / Given Name

Last / Surname

Email Address

Telephone (with country code)

Gender

Date of Birth

Passport Nationality

Substance Use

List substances used (alcohol, opiates, cannabis, benzodiazepines, methamphetamine, cocaine, etc.)

Duration of use (how long, number of months or years for each)

Amount per day for the substances

Route taken to use the substances (drink, smoke, inject, swallow, etc.)

Approximate date of last use of each substance

Other information about substances we should know about (if applicable)

Health Background

Indicate if you have or have had any of the following health issues:

For any of the health issues above, please provide more detail, and any medications used to treat these conditions.

Indicate if you have experienced any of the following:

For any of the health issues above, please provide more detail, and any medications used to treat these conditions.

Please describe other health issues not mentioned above, if any.

Please list any currently prescribed medication and dosages not mentioned above, if any.

Please indicate if you have any mobility issues. Note that Serenity Rehab is not wheelchair-accessible, and there are stairs at our facility.

Previous Addiction Treatment

If you have attended any other rehab programmes in the past, please list, and indicate the dates of attendance, and the length of abstinence from substances after each rehab.

Arrival and Logistics

Prefered dates to begin rehab

Allergies or special dietary needs

I've read and accept the terms and conditions.