Contact Us      Free Online Assessment
 

Free Online Assessment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

Feel out the free online assessment form below and give us as much information as you feel we need in order to help you. You will notice the form can be filled out either by the self medicater or by a friend or family member.
 

First Name:       

Last Name:       

City, State       

Phone:              

E-Mail:              

Is this regarding you?
Yes
No

If not, how are you connected/related to this person

What is the age of the Self Medicater or Addict?

Drug History:

Please indicate which drug(s) are involved
Main Drug                      Second Drug                     Third Drug
             

How Used?
Pills  Smoking  Intravenous  Snorting

Briefly describe this person's drug history


What problems has using medications caused the addict?

What problems has using medications caused their family?

What is the worst problem facing the self medicater?

Please describe briefly what is the current scene with this person.

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