Treatment Terms

Re-ha-bil-i-tate:

Restore to effectiveness or normal life by training.

Ad-dic-tion:

Compulsive physiological and psychological need for a habit-forming substance.

Drug:

A chemical substance, such as a narcotic or hallucinogen, that affects the central nervous system, causing changes in behavior and often addiction.

Assessment Form

Your Name: 
Email: 
Home Phone #: 
Cell Phone #: 
Work Phone #: 
Address: 
City: 
State: 
Postal Code: 
Country: 
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)


Is the addict on any medication for any of the above?

yes no

Which Medications? 

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?

All the information provided is held in strict confidence


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.
 
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