Admissions Application

Begin Your Recovery Journey

Use this secure form to request admission assessment and rehabilitation support from ARC.

In Crisis? If you or someone you know is in immediate danger, call 193 (Emergency). You can also contact ARC on +233 59 766 3466 for assistance.

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Applicant Type

Who is completing this application?

Self

Applying for myself

Family / Friend

Concerned about someone

Legal Guardian

Acting on behalf of a minor

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Client Details

Basic information about the person requiring treatment.

Full Name *

Age *

ARC generally admits clients aged 16–65. Ages 13–16 require specialised arrangements with ARC.

Must be between 13 and 65 years old. ARC generally admits clients aged 16–65; ages 13–16 require specialised arrangements.

Gender

Location (City / Region)

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Urgency & Medical History

Urgency Level *

Routine

Can wait a few days

Urgent

Within 24 - 48 hours

Crisis

Immediate intervention needed

Medical Conditions / Allergies Please provide only information relevant to this admission enquiry. ARC will handle submitted information as confidential.

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Contact Information

How can we reach the person listed above (or you)?

Contact Person Name *

Phone Number *

Email Address

Relationship to Client

Best Time to Contact

Preferred Contact Channel

WhatsApp Phone Call Email

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Consent & Submission

Privacy & Confidentiality Notice: This form may collect sensitive personal and health information. ARC will use the information to review and respond to this admission enquiry and handle it in line with its privacy and confidentiality procedures. Please review our Privacy Policy.