Prevention of and Treatment for Substance Abuse Act, 2008 (Act No. 70 of 2008)

Regulations

Regulations for Prevention of and Treatment for Substance Abuse, 2013

Annexures

Annexure F : Forms

Form 4 : Application for registration of a treatment centre

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FORM 4

APPLICATION FOR REGISTRATION OF A TREATMENT CENTRE

IN TERMS OF THE PREVENTION OF AND TREATMENT FOR SUBSTANCE ABUSE ACT, 2008 (ACT NO. 70 OF 2008)

[Regulation 27]

The following documents must be attached to the application for registration of a private treatment centre:

1.	Feasibility study

2.	A copy of the constitution of the facility.

3.	Rezoning certificate/Letter confirming whether rezoning of land is possible (where applicable).

4.	Local Authority building plans/schematic sketch of building.

5.	Detailed treatment programme.

6.	Daily programme.

7.	House rules for residents.

8.	Admission criteria.

9.	Financial statements (of the previous year, where applicable)

10.	Means test.

11.	Medical and psychiatric treatment policy.

12.	Management structure and staff component.

13.	Nutritional progamme [sic].

13.	Fees structure.

14.	Business Plan

PART A

IDENTIFYING PARTICULARS OF FACILITY

1.	Name of facility

__________________________________________________________________________

Address

__________________________________________________________________________

Tel: ___________________________________________________________________

Fax: ___________________________________________________________________

E-mail address: ____________________________________________________________

__________________________________________________________________________

Emergency number: ________________________________________________________

Registration number of company/NPO number

__________________________________________________________________________

2.	Area/s of operation

__________________________________________________________________________

Buildings

(a)	Description of building/buildings

__________________________________________________________________________

(b)	Will there be any other buildings and/or activities on the site other than the proposed facility? If so, provide details:

__________________________________________________________________________

5.	Details of other registered facilities, in your area/s.

Name of facility

__________________________________________________________________________

PART B

SITUATION ANALYSIS

1.	What clinical disciplines are/will be practiced in the facility?

__________________________________________________________________________

(Use separate sheet if necessary)

2.	What is the extent of the present demand for the services that is/will be provided?

__________________________________________________________________________

(Use separate sheet if necessary)

3.	Have you taken into account existing private and public facilities in your calculation and projections. If yes, how?

__________________________________________________________________________

(Use separate sheet if necessary)

4.	Any other information deemed necessary for this application

__________________________________________________________________________

PART C

PATIENT PROFILE

1.	Number of residents for which registration is required:

Adults: Males

_________________________________ Females ______________________________

Children

Males ___________________________ Females ________________________________

Total ____________________________

2.	Will you provide out-patient services? If Yes, supply details

__________________________________________________________________________

(Use separate sheet if necessary)

3.	Treatment period

Time Frame

Short Term (6 weeks)

Long Term (6 weeks +)

Re-admission

4.	Specify special programmes for long term treatment e.g. education:

Skills training:

__________________________________________________________________________

5.	What arrangements are being made with reference to detoxification:

__________________________________________________________________________

6. Specify the dependency producing substance applicable to patients treated or to be treated at the treatment facility

	Alcohol	Dagga	Mandrax	Heroin	Cocaine	Crack	Ecstasy	LSD	Inhalants	Pre- scription drugs	Other
Adult males
Adult females
Male children
Female children

PART D

MANAGEMENT STRUCTURE

1.	Portfolio name address & contact details

__________________________________________________________________________

2.	Profession, qualification and experience

Chairperson _______________________________________________________________

Vice-chairperson __________________________________________________________

Treasurer _________________________________________________________________

Secretary _________________________________________________________________

Other ____________________________________________________________________

__________________________________________________________________________

PART E

PERSONNEL

Provide a detailed list of your staff established containing the following information: Name, profession, name of board/council, registration number and salary (state whether employees are employed on full time/part-time basis)

_________________________________________________________________________________

The applicant hereby applies for registration as a treatment centre in terms of the Prevention and Treatment of and Prevention for Substance Abuse Act, 2008

SIGNED:

CHAIRMAN OF THE APPLICANT (in the case of an existing treatment centre):

FULL NAMES AND SURNAMES:

_________________________________________________________________________________

DATE:

_________________________________________________________________________________

WITNESSES (Management structure members)

_________________________________________________________________________________

Prevention of and Treatment for Substance Abuse Act, 2008 (Act No. 70 of 2008)

Regulations

Regulations for Prevention of and Treatment for Substance Abuse, 2013

Annexures

Annexure F : Forms

Form 4 : Application for registration of a treatment centre

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