Obstacles are those frightful things you see when you take your eyes off your goals.

~ Author Unknown

Confidential Assessment

This free confidential assessment can be completed by the individual, friend, or loved one to obtain an unbiased confidential assessment of whether treatment or other services are needed. The information will be submitted and maintained in strictest confidence.

Any questions with an asterisk (*) are important to help conduct the best possible assessment about you or your loved one. Therefore, those entries marked by asterisks should be completed before this submission can occur.

Please enter the folllowing information:
First Name*:
Last Name*:
Email Address*:
Your Phone #1*:	999-999-9999
Phone #2:	999-999-9999
Phone #3:	999-999-9999
Your Relationship to the Person Seeking Services*:	name:
Best Time to call:
Age of the Person Seeking Services*:
Does the individual want help?*:
Does the individual believe she or he has a problem?*:
What is the individual's drug of choice?*:	if other,
What other drugs does she or he use currently or in the past?*: You can select several options using ctrl+click
What other addictions are present?*: You can select several options using ctrl+click	if other,
Has she or he ever been diagnosed by a professional as having an addiction? :
At what age did the addictive behavior or substance use begin?:	don't know
What was his or her longest period of abstaining from the addictive behavior or substance?:
Has she or he ever been treated for an addiction?:	if yes, (How many times)
If she or he has been treated, when was the last treatment?:
What other emotional diagnoses or concerns are present?*:	if other,
Describe your current concerns about the effects of the addiction and/or emotional condition:
Does she or he have any medical problems?*:	if yes,
Does she or he have any legal involvement?*:	if yes,
Does she or he have insurance?*:

Not all required information has been entered. Please enter your answers and click Submit again.

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