Confidential Online Assessment

Fill Out The Form Below To Receive A Call From One Of Our Qualified Addiction Specialists
Note: any and all information submitted is completely confidential

First Name: *	Please enter the first name.
Last Name: *	Please enter the last name.
E-mail Address: *	Please enter an Email address.
Phone Number: *	Please enter a phone number.(xxx-xxx-xxxx)
Evening Phone: *	Please enter a phone number.
Cell Phone: *	Please enter a phone number.
You are Contacting a Drug Addiction Specialist for:	Self Family Member Husband Wife Friend Employee Patient Client Other Invalid Input
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If Contacting a Drug Addiction Specialist for Someone Other Than Yourself, Please Enter Their Name:	Invalid Input
Best Time To Call:	Invalid Input
Drug History
What Is The Primary Drug of Abuse?	AlcoholCocaineCrackHeroinMethamphetamineEcstasyGHBInhalantsKetamineLSDMarijuanaMethadonePCPPrescription DrugsOther Invalid Input
Method of Intake?	UnsureSmokedSnortedOrallyIntraveneous Invalid Input
What Is The Secondary Drug of Abuse?	AlcoholCocaineCrackHeroinMethamphetamineEcstasyGHBInhalantsKetamineLSDMarijuanaMethadonePCPPrescription DrugsOther Invalid Input
Method of Intake?	UnsureSmokedSnortedOrallyIntraveneous Invalid Input
At What Age Did The User First Take Drugs?	Invalid Input
How Old Is The User Now?	Invalid Input
At What Age Did The User’s Life Begin To Be Unmanageable?	Invalid Input
Presently What Are The Resulting Problems of The User’s Addiction?	Invalid Input
What Is The Family’s Attitude Toward The User’s Addiction?	Invalid Input
Does The User Admit To Having A Problem?	Yes  No  Invalid Input
Does The User Want Help?	Yes  No  Invalid Input
Treatment History
How Many Times Has This User Been In Treatment For Their Addiction?	Never1-23-56 or More Invalid Input
How Many of These Involved The 12-Step (AA/NA Model) Approach To Recovery?	AllSomeNone Invalid Input
Was There Any Success With Any Of These Treatment Episodes, and if so what was the length of sobriety achieved?	Invalid Input
Medical History
Does The User Have Any Known Medical Conditions?	YesNo Invalid Input
If, So Please List The Condition(s) And Any Necessary Details:	Invalid Input
Has This Person Ever Been Diagnosed With Any Psychiatric Disorders?	YesNo Invalid Input
If, So Is He / She Currently On Medication For A Psychiatric Disorder?	YesNo Invalid Input
If, So Please Specify Medications Taken:	Invalid Input
Does The User Have Medical Insurance?	YesNo Invalid Input
Does The User Have Legal Issues?	YesNo Invalid Input
If, So Please Describe:	Invalid Input
Please Provide Us With Any Other Information And Any Questions You May Have:	Invalid Input
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