Confidential Online Assessment

Fill Out The Form Below To Receive A Call From One Of Our Qualified Addiction Specialists.
Our team is dedicated to helping you navigate the complexities of addiction and finding the most effective treatment options available. Whether you’re just beginning your journey or looking for additional support, we’re here to guide you every step of the way. By connecting with our specialists, you’ll gain access to valuable resources like personalized treatment plans and professional advice. Visit https://www.methadone.org/treatment-guide/ for more information about how methadone can be an essential part of your treatment. Together, we can help you take meaningful steps toward a healthier future and long-term recovery.

Note: any and all information submitted is completely confidential

First Name: *

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Last Name: *

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E-mail Address: *

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Phone Number: *

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Evening Phone: *

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Cell Phone: *

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You are Contacting a Drug Addiction Specialist for:








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If Contacting a Drug Addiction Specialist for Someone Other Than Yourself, Please Enter Their Name:

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Best Time To Call:

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Drug History
What Is The Primary Drug of Abuse?

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Method of Intake?

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What Is The Secondary Drug of Abuse?

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Method of Intake?

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At What Age Did The User First Take Drugs?

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How Old Is The User Now?

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At What Age Did The User’s Life Begin To Be Unmanageable?

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Presently What Are The Resulting Problems of The User’s Addiction?

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What Is The Family’s Attitude Toward The User’s Addiction?

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Does The User Admit To Having A Problem?

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Does The User Want Help?

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Treatment History
How Many Times Has This User Been In Treatment For Their Addiction?

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How Many of These Involved The 12-Step (AA/NA Model) Approach To Recovery?

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Was There Any Success With Any Of These Treatment Episodes, and if so what was the length of sobriety achieved?

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Medical History
Does The User Have Any Known Medical Conditions?

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If, So Please List The Condition(s) And Any Necessary Details:

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Has This Person Ever Been Diagnosed With Any Psychiatric Disorders?

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If, So Is He / She Currently On Medication For A Psychiatric Disorder?

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If, So Please Specify Medications Taken:

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Does The User Have Medical Insurance?

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Does The User Have Legal Issues?

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If, So Please Describe:

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Please Provide Us With Any Other Information And Any Questions You May Have:

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