YOUR RESOURCE HELP LINE

  
 
The time to act is now. When faced with substance abuse problems, time is a crucial factor. When attempting to place the person into a treatment program, one will find a very short time window of opportunity before the individual changes his mind. When that happens all will have to wait for the next unfortunate situation to arise, which shocks the individual into reality again, and he reaches for help. That is a very dangerous game to play, as the losers prize is almost certainly death or jail We suggest that you pick up the phone and give us a call now, speak with one of our assessment counselors and together determine the right program for the person with the problem. We can help coordinate a smooth transition, offer instruction and advice, at times provide intervention services to assist the family in handling this delicate situation successfully.
So call us today
Toll Free
866-977-2684
Or simply fill out the form below and we will contact you

Your Name:
Email :
Phone #:       Home
Home    Work    

Cell   Fax                         

Address:
City: State: Postal Code:

Person you wish to help ?   self   other

      If other, who are you concerned about:
     Name: Relationship:

How old is the addict ?

Does the addict want help ?   yes   no

Please list drugs abused:
     Primary:
  		Second:
  		Third:
  		 

How does the addict obtain drugs/alcohol ?  
       Works     Steals     Prescription     Deals     Other

Please describe any personal / family problems the addict has.
     

Please describe any legal problems the addict has.
     

Please describe the overall behavior & condition of the addict.
      

Is there any diagnosed medical condition? (Please describe)
     

Is there any diagnosed mental disorder? (Please describe)
      

Did the addict on any medication for any of the above?   yes   no

     Medication?

How long ?

Has the person ever attempted to stop using drugs before ?   yes   no

     If so, by which method?

       Self     112-step     Non-Hospital Residential     Hospital     Other

If the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)
       

Was it a private program or a state-funded program ?   private   state-funded

Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)
     

Is there anything else you would like us to know?
     

DRUG REHAB RESOURCE
     


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Last updated 4/16/08