US Drug Rehabilitation Centers

US Drug Rehabilitation Operator

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Assessment Form

Please fill out this information form as completely as possible so that we can provide you with the best help possible. We will help you find a good rehabilitation facility with a high success rate and which method does not use any kinds of drugs in the program which actually achieves a complete rehabilitation.
Your Name:
Email :
Phone #:
Cell #:
Work #:
Address:
City: State:
Country:
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:

How does the addict obtain drugs/alcohol ? 
     Works  Steals  Prescription  Deals  Other

Please describe any personal / family problems the addict has.


Please describe any legal problems the addict has.


Please describe the overall behavior & condition of the addict.


Is there any diagnosed medical condition? (Please describe)


Is there any diagnosed mental disorder? (Please describe)


Did the addict on any medication for any of the above? 
     yes  no 
Medication?  How long? 

Has the person ever attempted to stop using drugs before ?
     yes  no 
     If so, by which method?
     Self  12-step  Non-Hospital Residential  Hospital  Other

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


Was it a private program or a state-funded program ? 
     private  state-funded 
 
    Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)


Is there anything else you would like us to know?


    


 




1-877-325-1982