Wednesday, 22 Feb 2012
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Detailed Assessment Form
First Name:
Last Name:
Email:
Phone Number:
State:
Who you are contacting us for:
Name (if contacting for someone other than yourself):
Preferred method of contact:
Best time of day to contact you:
Select the drugs that are primarily being abused:
Alcohol
Prescription Pain Killers (Vicodin, OxyContin, Morphine)
Prescription Benzodiazepines (Klonopin, Xanax,Valium)
Cocaine
Crack
Heroin
Methamphetamine
Marijuana
Methadone
GHB
Ecstasy
Inhalants
Ketamine
PCP
LSD
Other Drug
Eating Disorder (like anorexia, bulimia)
Sexual Addiction
Gambling Addiction
Other Addiction
Age first started using:
Current age:
Resulting problems of the addiction:
Do you, or the user, admit to having a problem?
Do you, or the user, want to receive help?
Are you, or the user, able and willing to leave home in order to get the right treatment?
Please list any mental health problems, and/or any other serious medical conditions:
Select the type of medical insurance you, or the user has:
For private rehab, how much money is available out of pocket?
Please list any legal situations you, or the user, are currently involved in:
History of Drug Use
Medical Information
Protection Code:
Please, enter the text shown in the image into the field below.
*All information is completely confidential*