Siam Rehab Admissions Form

Home » Siam Rehab Admissions Form

Medical care is provided by Dr. Mark Sukkhosawat, a licensed psychiatrist and general practitioner M.D. specializing in substance addiction treatment, with 19 years of experience.

Siam Rehab Admissions Form

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

Review the admissions requirements (below)
Submit the Siam Rehab Admissions Form (this page)
Discuss the admissions request with Siam’s Admissions Manager
Upon approval, set arrival date and addiction treatment length
Make deposit or full payment
Make flight reservations to Siam Rehab in Chiang Rai
Travel to Siam Rehab to begin the treatment programme

Rehab Admissions Form

Contact Information

First / Given Name*

Last / Surname*

Email Address*

Telephone (with country code) *

Gender*

Date of Birth *

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

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 Siam 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

Preferred dates to begin rehab*

Allergies or special dietary needs*

I've read and accept the terms and conditions*

Siam Rehab Admissions Form

Siam Rehab Admissions Form

Rehab Admissions Form

Quick Access

Quick Access

Quick Access

Quick Access

ABOUT SIAM REHAB