Registration Form

You can apply for treatment by phone or mail. You need a valid and specific referral from your (family) physician before we will take any further steps. You can read more about the intake procedure here .

Name(Required)
Gender(Required)
Date of birth(Required)
Address details
Are you currently in treatment?(Required)
Please note that the referral letter must be in our possession before an intake can take place.
Consent knowledge fees and deductible(Required)
Consent cancellation terms agreements(Required)