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 5 : Application for registration of a private halfway house

Purchase

FORM 5

APPLICATION FOR REGISTRATION OF A PRIVATE HALFWAY HOUSE

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

(Regulation 30)

The following documents must be attached to the application for registration of a private halfway house:

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.	Daily programme.

6.	House rules for residents.

7.	Admission criteria.

8.	Financial statements of the previous year where applicable

9.	Means test.

10.	Medical and psychiatric treatment policy.

11.	Management structure and staff component.

12.	Nutritional programme.

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

_______________________________________________________________________________

(Use separate sheet if necessary)

PART C

PATIENT PROFILE

1.	Number of service users to be accommodated in a treatment centre 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 on-going abstinence;

_______________________________________________________________________________

PART D

MANAGEMENT STRUCTURE (only in the case of a halfway house already in existence)

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 bases)

______________________________________________________________________________________

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

SIGNED:

CHAIRMAN OF THE APPLICANT:

FULL NAMES AND SURNAME:

______________________________________________________________________________________

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 5 : Application for registration of a private halfway house

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