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This information was VERY helpful,
probably even life-saving!
–Valerie M., Michigan
 
 

Evaluation Assessment Form (no cost)

Assessments and evaluations are designed to help determine whether a person has an alcohol or drug problem and recommend the best level of treatment. After submitting this form, a trained professional will respond with their findings.

Completely Confidential

All information is strictly confidential in accordance with the Federal HIPPA rights of privacy laws.

*** required field

your name
*** your e-mail address
*** re-verify exact e-mail address
Phone number  
Is this for you or someone else  
Age of the person
What drug(s) and/or alcohol are currently being abused
What other drugs has the person used in the past
Has the person ever been to rehab
How often does the person use drugs and/or alcohol
At approximately what age did the substance use begin not sure
Has the person ever suffered any real consequences as a result of drug/alcohol use
Does the person admit they have a drug or alcohol problem
Is the person willing to seek help

Does the person participate in any other compulsive or addictive behaviors

Has the person ever tried or talked about quitting
Are there any emotional issues present (depression, anxiety, anger)

Does the person have any special medical concerns

Does the person have any legal issues

Does the person have any insurance

Tell us any additional information about the person's using history, situation or behavior

How would you like us to respond phone e-mail
If by phone, what is a the best time