Accepting Patients for the Treatment of Opioid & Narcotic Dependence.
Confidential Screening Assessment Print E-mail
Assessment Form
This assessment is provided as a free public health services. A licensed alcohol and drug provider reviews all responses, and all information is strictly confidential.
*=Required information
 
YES
NO
MAYBE
*Do you feel you have a drug problem?
*Are you having problems at work, or school?
*Are you having problems at home?
*Does your family feel you have a drug problem?
*Do your friends feel you have a drug problem?
*Have you ever been arrested for drug related matters?
*Have you ever been in drug treatment?
*Have you participated in 12-step programs (AA, NA)?
*Do you use every day?
*Have you tried to stop using without lasting success?
*Do you have medical complications from drug use (Hepatitis, HIV/AIDS, etc.)?
*Have you ever been diagnosed with a psychiatric disorder?
Are you currently in treatment for any health condition – physical, mental, substance abuse?
       
This assessment is for:    
What is the drug of choice?   
   
What is your method of intake?    
   
*Do you want us to contact you?   

What is the best time to contact you?
May we leave a message with anyone?   
   
   
*My First Name:
*My Last Initial:
*Email address:
*Age:
Phone number:
*State:
   

 
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Fri. Sep. 10th, 2010