Confidential Assessment

Note: All information collected on this form is confidential.
Note: The * symbol denotes a required field.

First Name *

Last Name *

Your Email *

Your Phone # *

Alternate Phone #

State *

Who are you trying to get help for? *

If you are looking for help for someone else, please enter their name:

How should we contact you? *

If You'd rather us contact you by phone, what is the best time to reach you?

What are the primary types of abuse?

Drug History

At what age did you/the user first begin using drugs?

What are are you/the user now?

What problems have started as a result of your/the users addiction?

What is the family's attitude towards your/the users addiction?

Do you/the user admit to having a problem? *

Do you/the user want help? *

Are you/the user willing to leave the home area in order to get the best treatment available?

Medical History

Have you/the user been diagnosed with any mental health issues?

If you answered yes above, please list the issues and any necessary details:

Do you/the user have medical insurance? *

If you answered yes above, please select the type of insurance you/the user has:

If need be, how much out of pocket money is available for private rehabilitation?

Do you/the user have legal issues? *

If you answered yes above, please describe said issues:

Please enter any additional information or ask any questions you may have:

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