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Drug Rehabilitation Assessment Form

For immediate assistance, call us at  1-800-819-9973. Our certified chemical dependency counselors are ready to take your call 24 hours a day, 7 days a week.
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This online service is provided free of charge as a public benefit service and all information received from clients is confidential. Response time is usually 24 hours or less and is in the form of a confidential e-mail. In some instances, phone contact may be appropriate and necessary to better assess the situation, or in the case of an emergency where the call was requested by the individual. In the event of a phone call, the counselor will only identify themselves to the contact person listed below and will advise all others that this a personal call and will not disclose who we are or why we are calling. In assessing the problem and deciding on treatment options, several factors that are typically used in assessing an individual’s level of addiction.

These factors include:
  • Prior alcohol and drug use history 
  • Family history and Ethnic/Cultural background
  • Social history
  • Legal history
  • Educational history
  • Occupational history
  • Medical history
  • Psychological and behavioral problems.
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Below you will find questions pertaining to these areas, it is important that you answer them as accurately as possible. This information is requested, however, it is not required for a referral.

Please fill out the form below so we can access and refer your information to the treatment center which best suits your needs. Code 42 of Federal Regulations forbids parishioners to disclose the identities of persons inquiring about drug rehab services – even if they are never admitted to the facility.

For immediate assistance, give us a call now.  1-800-819-9973
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Please fill out this form and we can help you or someone you love find the best solution to any issues pertaining to drug and or alcohol addiction. For faster service, please call one of our counselors at 1-800-819-9973.
Your General and Contact Information:
your name
wife, father, son, self
Individual's General Information:
person in which you are inquiring for
A). Substance Abuse History:
B). Family History:
C). Social History
D). Legal History:
E). Educational History:
F). Occupational History
G). Medical History:
H). Psychological and Behavioral History:

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Free Online Drug and Alcohol Assessment
Service Type
Free Online Drug and Alcohol Assessment
Free online assessment for addiction
Free online drug assessment form for people to fill out to get help with drug abuse.

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