Begin the Healing Process

Please fill out the admission form below to submit a rehab application and one of our directors will reach out to you promptly. Should you require immediate assistance, feel free to phone us or send us a WhatsApp message.

We encourage you to learn about our basic requirements before to submitting your admission application.

Admission Form

Contact Information

Substance Use

List substances used

Duration of use

Amount per day per substance

How these substances were administered

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:

Asthma
Diabetes
Heart Condition
High Blood Pressure
Seizures
Other
None

For any of the health issues above, please provide more details, including 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 (Siam Rehab is not wheelchair friendly and there are stairs at the facility).

Previous Addiction Treatment

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

Arrival & Logistics

You acknowledge that the Siam Rehab admissions screening process is confidential and that you will not publicly disclose details about this process.By submitting, I agree to the processing and international transfer of my personal data by Siam Rehab as described in the Privacy Policy.

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