Drug and Alcohol Evaluations

  Have you been charged with an alcohol charge or a drug-related crime? Is your work or school recommending that you get an evaluation for drugs or alcohol?  If this is the case, you may be asked to complete a drug or alcohol evaluation or chemical health assessment. We provide this service, free of charge to help you begin the process of becoming drug-free.

Please note that this evaluation is not a legally binding document.

You will need to do a full evaluation IN PERSON. Please speak to your probation officer for more information.

These evaluations are to help you learn whether you need addiction treatment. If you need help locating a drug treatment program in lieu of jail time you can visit our Court Ordered Drug Rehabs page or call to speak to one of our certified addiction staff now.

1-800-513-5423

Before you begin your evaluation, we strongly recommend that you give us a call first. Our counselors and addiction specialists can help you understand the questions and possible outcomes that you could be facing. Being informed will help you understand the science behind the evaluation and could help you avoid consequences laid down by the court systems. We understand that when facing the possibility of jail time due to the consequences of drug abuse, can be stressful, to say the least. It is natural to have questions about what you can expect to go through during your evaluation for the courts, family, work, or personal reasons. Please call us today for immediate service. We can give you a cost estimate, and a price quote and find out if your insurance will pay for addiction treatment. Several factors are typically used in evaluating 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.

Our addiction treatment specialists and staff have over 25 years of experience in helping people find effective and affordable treatment for all addictions. We can help you verify if your insurance is in network with one of the treatment centers near you. What you tell us is completely confidential. No one will ever know that we spoke to you without your consent.

Please Note: This is not an official evaluation form. This form is not admissible in court or for probation officers and is not accepted by caseworkers. Addiction No More is here to help you find treatment for addiction. We can not give any legal advice. If you are looking for a rehab center please fill out this form or call us now.

Disclaimer: This evaluation is not intended to constitute a diagnosis of any disorder. The information provided here cannot substitute for a full evaluation by a health professional which must be done in person. Call us 24 hours a day, 7 days a week for help locating a treatment center for addiction.

1-800-513-5423

Free Evaluation Form

Call now for immediate service.

Your Name

Phone Number(Required)

Email Address(Required)

Your Relation to the Individual

Does this individual need treatment for addiction (detox/rehab)?

Individual's General Information

---

Individual's Name:

How old is the individual?

Gender

City and State in which they live:

Can they travel outside of this area for treatment?

yes

no

A. Substance Abuse History:

---

At what age did the individual start using the substance?:

Please enter a number from 1 to 100.

Current drug(s) being used:

Different drugs used:

Method of use:

Oral

IV (Inject)

Inhale (Smoke)

Nasal (Snort)

Other

Past treatment attempts (What rehab, when, results:)

B). Family History:

---

Marital Status

Any children?

yes

no

Who has parenting responsibilities?

History of physical or mental abuse?

yes

no

unsure

Any losses (death) or departures (divorce-separations) from the family institution?

Has the individuals peer structure changed?

yes

no

unsure

C. Social History:

---

Has there been a gradual shift to non-involvement in those activities? (if yes, when)

Has the individual enjoyed any social activities in the past? (if yes, specify)

Does anyone in the individual's immediate (blood) family have/or had a substance abuse problem?

yes

no

unsure

D. Legal History:

---

Does the individual have a valid drivers license?

yes

no

unsure

Has the individual ever been arrested? (If so, for what)

Are any crimes actively being committed to support, or as a result of the alcoholism or addiction?

E. Educational History:

---

Highest grade completed in grade school

9th10th11th12thsome collegecollege graduate

Vocational Tech?

Yes

No

Any desire or plan of continued or future education?

F. Occupational History:

---

Occupation

How Long?

Is this the individuals chosen occupation?

yes

no

unsure

If not chosen profession, what is?

Has the individual ever been terminated as a result of substance abuse?

G. Medical History:

---

Does the individual have any medical problems? (Please describe)

Is the individual currently taking any medications?

yes

no

unsure

If yes, please specify what and length of use:

H). Psychological and Behavioral History:

---

Has the individual ever been diagnosed and treated for any psychological or emotional problems?

yes

no

unsure

Was the individual prescribed medication for any psychological/emotional problem ?

yes

no

unsure

If yes, please list what drugs where prescribed and length of use:

Additional Information or Comments

On a Scale of 1-10, with 10 representing extreme urgency, and 1 representing information for later use. Please assign a number to this request

12345678910

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Phone

This field is for validation purposes and should be left unchanged.

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Sources
Screening
What is an assessment?
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Erik Epp – Content Author