Assessment Form

Note: any and all information submitted is completely confidential

First Name
Last Name
Email Address
Phone Number
Alternative Phone
State
You Are Contacting Us for:
If You Are Contacting Us for Someone Other Than Yourself, Please Enter Their Name Here:
Select Your Time Zone
Preferred Method of Contact
If You Prefer to Contacted by Phone, Please Provide The Best Time to Call:

What is/are The Primary Drug(s) of Abuse?

Alcohol

Cocaine

Crack

Heroin

Methamphetamine

GHB

Ecstasy

Inhalants

Ketamine

Prescription Pain Killers (Morphine, OxyContin, Vicodin, Fentanyl)

Prescription Benzodiazepines (Xanax, Klonopin, Valium, etc.)

PCP

Marijuana

Methadone

LSD

Other Drug

Eating Disorder (Anorexia, Bulimia, Binge Eating, Overeating)

Other Addiction

Drug History
At What Age Did The User First Take Drugs?
How Old Is The User Now?
What Are The Resulting Problems of The User's Addiction?
What Is The Family's Attitude Toward The User's Addiction?
Does The User Admit to Having a Problem?
Does The User Want Help?
Is The User Willing to Leave His/Her Home Area to Get The Best Treatment Available?
Medical History
Has The User Been Diagnosed With Any Mental Health Problems?
If Yes, Please List The Conditions And Any Necessary Details
Does The User Have Medical Insurance?
If Yes, Please Select The Type of Insurance The User Has
If Necessary, How Much Out-of-Pocket Money is Available for Private Rehab?
Does The User Have Legal Issues?
If Yes, Please Describe
Please Provide Us With Any Additional Information or Questions You May Have Here: