Confidential Online Drug Alcohol Assessment


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Note: any and all information submitted is completely confidential

*First Name: *Last Name:

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You are contacting Drug and Alcohol Rehab Services for:
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Employee
Patient
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If Contacting Drug and Alcohol Rehab Services  For Someone Other Than
Yourself, Please Enter Their Name Below:

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Drug History
What Is The Primary Drug of Abuse?

Method of Intake?

What Is The Secondary Drug of Abuse?

Method of Intake?

At What Age Did The User First Take Drugs?

How Old Is The User Now?

At What Age Did The User's Life Begin To Be Unmanageable?

Presently What Are The Resulting Problems of The User's Addiction?

What Is The Family's Attitude Toward The User's Addiction?

Does The User Admit To Having A Problem? yes  no 

Does The User Want Help ?  yes  no 



Treatment History

How Many Times Has This User Been In Treatment for Their Addiction?

How Many of These Involved The 12-Step (AA/NA Model) Approach To Recovery?

Was There Any Success With Any Of These Treatment Episodes, and if so, what was the length of sobriety achieved?

Medical History

Does The User Have Any Known Medical Conditions?

If So, Please List The Condition(s) And Any Necessary Details:

Has This Person Ever Been Diagnosed With Any Psychiatric Disorders?

If So, Is He / She Currently On Medication For A Psychiatric Disorder?

If So, Please Specify Medications Taken:

Does The User Have Medical Insurance?

Does The User Have Legal Issues? 

If So, Please Describe

Please Provide Us With Any Other Information And Any Questions You May Have In The Area Below