Drug Rehabilitation Assessment Form
For immediate assistance, call one of our certified chemical dependency counselors. They are ready to take your call 24 hours a day, 7 days a week.
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 use and drug use history
- Family history and Ethnic/Cultural background
- Social history
- Legal history
- Educational history
- Occupational history
- Medical history
- Psychological and behavioral problems.
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.