Please fill out the form below to get an assessment from a certified drug and alcohol treatment counselor. Please fill out as much information as you can. The more information we have, the better we can help you on your road to recovery. If you need to talk in person, please call 1-800-515-3277.

Confidential Online Assessment

1. Your Name:(required)
2. Email:(valid email required)
3. Primary Phone Number:(required)
4. Secondary Phone Number:
5. State Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming (required)
6. Who is the Rehab Service For Select Self Family Member Husband Wife Friend Employee Patient Client Other (required)
7. If Contacting Rehab Services For Someone Other Than Yourself, Enter Name Below:
8. Select Your Time Zone Select Eastern Central Mountain Pacific
9. Best Time to Call

Drug History

1. What is the Primary Drug of Abuse? Select Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Drugs Other Unsure
2. What is the Primary Drug of Abuse? Select Unsure Intravenous Smoked Snorted Orally
3. What is the Secondary Drug of Abuse? Select Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Drugs Other Unsure
4. What is the Secondary Drug of Abuse? Select Unsure Intravenous Smoked Snorted Orally
5. Age User First Took Drugs
6. Age of Drug User
7. Age When Did Drug Use Become a Problem for User?
8. What is the Status of the User Now?
9. Loved One's Attitude Toward Drug User
10. Does User Admit to Having a Problem? Select Yes No
11. Does User Want Help? Select Yes No

Treatment History

1. Number of Times User Has Been to Addiction Treatment? Select Never 1-2 3-5 6 or More
2. Did These Addiction Treatments Involve a 12 Step (AA/NA Model)? Select Some All None
3. Length of Sobieity Before Relapse

Medicial History

1. Does User Have Any Known Medical Conditions? Select Yes No
2. If So, Please List All Conditions in Detail
3. Does User Have Any Psychiatric Disorders? Select Yes No
4. If So, Does User Take Medication For Psychiatric Disorder? Select Yes No
5. If So, Please Specify Medication Taken:
6. Does User Have Medical Insurance? Select Yes No
7. Does User Have Legal Trouble? Select Yes No
8. If So, Please Descirbe
9. Please Provide Any Other Information or Questions You May Have Here

 

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