Application 

Sopnokoti Rehabilitation Center

Admission Application Form

Date: ______________________

Personal Information

1. Full Name: ____________________________________________
   
   

2. Father’s/Mother’s/Guardian’s Name: ________________________
   
   

3. Date of Birth: ___________________
   
   

4. Age: _______
   
   

5. Gender: ☐ Male ☐ Female ☐ Other
   
   

6. Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed
   
   

7. Present Address: ________________________________________
   
   

8. Permanent Address (if different): ___________________________
   
   

9. Contact Number: __________________________
   
   

10. Email (if any): __________________________
    
    

Emergency Contact Information

1. Name of Emergency Contact: _____________________________
   
   

2. Relationship to Applicant: ________________________________
   
   

3. Address: ______________________________________________
   
   

4. Two Contact Number: __________________________
   
   

Medical & Psychological Information

1. Reason for Seeking Rehabilitation:
   
   

2. Type of Addiction or Condition (if applicable):
   ☐ Drug Addiction
   ☐ Alcohol Addiction
   ☐ Mental Health Treatment
   ☐ Physical Rehabilitation
   ☐ Other (please specify): ______________________
   
   

3. Duration of the Problem: ________________________________
   
   

4. Any Previous Treatment or Rehabilitation?
   ☐ Yes ☐ No
   If yes, specify where and when: ______________________________
   
   

5. Current Medications (if any): _____________________________
   
   

6. Any Medical Conditions (e.g., diabetes, heart disease):
   
   

Declaration

I, __________________________________, declare that the information provided above is true and complete to the best of my knowledge. I agree to follow all the rules and regulations of the Sopnokoti Rehabilitation Center and participate in its treatment and recovery programs sincerely.

Applicant’s Signature: ___________________________
Date: ___________________

Guardian’s Signature (if applicable): ___________________________
Date: ___________________