Confidential Assessment

Please fill out this short form to receive a confidential assessment:

Required fields are indicated by *

Chemical Dependency Confidential Assessment Form
First Name: *
Last Name:
Email address: *
State: *	--- Choose A State --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin Wyoming
Phone:	-Type- Home Mobile Work
Inquiring About:	Yourself Family Member Friend Co-Worker Other
Age of addict:
Individual's First Name:
Individual's Last Name:
Individual's State: *	--- Choose A State --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin Wyoming
Primary Drug:
Last Used:
Amount:
Method:	-Select One- Orally Smoked Snorted Intravenous Other/Unsure
Other Drug:
Last Used:
Amount:
Method:	-Select One- Orally Smoked Snorted Intravenous Other/Unsure
Preferred method(s) of payment (select one or more):
	Private insurance Self-pay Need financing
Briefly describe the drug history of the addict:
What problems has addiction caused the addict?
What problems had addiction caused the family?
What kind of help do you think the addict needs?
Current Medications:
Other Comments: