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Drug Addiction Recovery Assessment

Please fill out our online assessment form so we can help you find the best treatment center for your needs. All information is strictly confidential and will only be given to other chemical dependency counselors so we can better serve you. A Recovery Assistance representative will contact you shortly to help you find an alcohol or drug addiction recovery center.

OR CALL US NOW FOR HELP FINDING A TREATMENT RECOVERY CENTER 1-888-781-7060

Your Name:

Email :

Phone #:

Address:

City:

State:

Postal Code:

Person you wish to help ? self other

If other, who are you concerned about:

Name:

Relationship:

How old is the addict ?

Does the addict want help ? yes no

Please list drugs abused:

Primary:

Second:

Third:

Please describe any personal / family problems the addict has.

Please describe any legal problems the addict has.

Please describe generally how the addict behaves at present.

Does the addict suffer from any present medical conditions? (Please describe)

Has the addict been diagnosed with a mental disorder? (Please describe)

Has the addict ever been prescribed Psyciatric drugs? (prozac, wellbutrin, rittalin,etc) yes no

Medication?

How long ?

Medication?

How long ?

Medication?

How long ?

Is the addict presently on any other prescription medication yes no

If so please descibe.

Has the addict been to prior drug and alcohol treatment? yes no

If so, by which method?

Self

12-step

Non-Hospital Residential

Hospital

Other

If the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)

Treatment 1

Treatment 2

Treatment 3

How was the program funded? private state-funded

Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)

General information about the addict or family?