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Please fill out our confidential assessment form. We ask for a lot of information because we have found that it makes the search for the proper program much faster, and we are much better prepared when we speak with you. So, please take your time and do your best so that we may better serve you.

*  Indicate these fields are required
Your Name  *
Your Email  *
Your Phone Number  *
Addict's Name:  *
Addict's Age:  *
Addict's Relationship to you:
What drugs or alcohol is the addict using?:
How long has the addict been using?:
Is the addict's behavior negatively affecting their home life? Explain:
Is the addict's behavior negatively affecting their job? Explain:
Has the addict's behavior caused legal problems or criminality? Explain:
Does the addict have any mental problems or been diagnosed with any psychiatric disorder? Explain:
Does the addict take any doctor prescribed medications? If so, which ones?
Does the Addict realize they have a problem?:
Has the addict tried treatment before?:
What kind of treatment?:
How long was the treatment?:
What were the results?:
Is the addict CURRENTLY motivated to go to treatment?:
If Unwilling, are you interested in an intervention?:
What are your main factors in considering a drug or alcohol rehabilitation program? Explain:
Are there any types of programs you want to specifically avoid? Explain:
How soon would you like to get the addict to treatment?:
Is there any other information you feel would be important to determine the right treatment program?:
Security Code: