Drug and Alcohol Rehabilitation Assessment and Referral

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

Select Your Time Zone: Pacific Mountain Central Eastern    Best Time To Call:

Drug History

What Is The Primary Drug of Abuse? Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Drugs Other
Method of Intake? Unsure Smoked Snorted Orally Intraveneous

What Is The Secondary Drug of Abuse? Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Drugs Other
Method of Intake? Unsure Smoked Snorted Intraveneous Orally

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? Never 1-2 3-5 6 or More

How Many of These Involved The 12-Step (AA/NA Model) Approach To Recovery? All Some None

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? No Yes

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

Has This Person Ever Been Diagnosed With Any Psychiatric Disorders? No Yes

If So, Is He / She Currently On Medication For A Psychiatric Disorder? No Yes

If So, Please Specify Medications Taken:

Does The User Have Medical Insurance? No Yes

Does The User Have Legal Issues?  No Yes

If So, Please Describe

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