Confirm E-mail Address
Second Phone Number
Who are you inquiring about treatment for?
Enter name of person in need of treatment
How did you hear about us?
Has the user completed a phone or online assessment with us before?
If yes, when?
Primary Drug of abuse
At what age did the user first take the primary drug?
How old is the user now?
As a result of substance abuse has the user suffered any legal consequences?
If so, please briefly explain
How many times has the user been to treatment?
Has the user been involved with any aa/na or other 12-step groups?
Has the user engaged in any other addictive behaviors? i.e. Eating disorder, gambling, sex addiction?
Please briefly explain.
Has the user ever been diagnosed with a psychiatric disorder?
If so, what was/is the Doctors diagnosis?
Is she/he currently taking medication for a psychiatric disorder?
If known, please list psychiatric medications:
Does the user have any known medical problems other than psychiatric?
If so, explain:
If known, please list any medications that the user is taking as a result of these medical issues:
Please provide us with any other information you may have:
Are there any questions you have about our program?
Indicates Response Required