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:
Other

How should we contact you? *

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

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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