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Confidential Drug and Alcohol Rehab Assessment

Call Toll Free 1-866-418-1397 For Help Now!

This online service is provided free of charge as a public benefit and all information received from clients is confidential. Response time is usually 24 hours or less, and usually is in the form of a confidential e-mail first, then a possible telephone interview. In most instances an OUTREACH SERVICES specialist/counselor will attempt a phone contact to better assess the situation. In the event of a phone call OUTREACH SERVICES will only identify themselves to the contact person listed below, and will advise all others that this is a personal call and will not disclose who we are or why we are calling. The below request for information is gathered to help the placement specialist better determine an individual's needs and successfully match them with the best possible level of care available for them. Please fill out the confidential online assessment form to the best of your ability. All fields are not required, and remember - disclosing personal information is not required for assistance or a treatment referral. Confidentiality is of the utmost importance and here at Outreach Services choices for Drug and Alcohol Rehab Services is our priority. We're here to help.

Thank You ,
Outreach Services

Confidential Online Assessment Form

Fill out the form below to receive a call from one of our qualified Addiction Specialists.
Note: Any and all information submitted is completely confidential.
First Name:
Last Name:
Email Address:
Phone Number:
Evening Phone:
Cell Phone:
State:
 
You are contacting Outreach Services for Drug and Alcohol Rehab referrals for:
Self
Family Member
Husband
Wife
Friend
Employee
Patient
Client
Other
If Contacting Outreach Services for Drug and Alcohol Rehab Services  For Someone Other Than Yourself, Please Enter Their Name Below:
Your Time Zone:
 
Best Time to Call:
Drug History
What Is The Primary Drug of Abuse?
 
Method of Intake:
 
What is The Secondary Drug of Abuse?
 
Method of Intake:
At What Age Did the User First Take Drugs?
How Old is the User Now?
At What Age Did The User's Life Begin To Be Unmanageable?
Presently What Are The Resulting Problems of The User's Addiction?
What Is The Family's Attitude Toward The User's Addiction?
Does the User Admit to Having a Problem?
Yes
No
Does the user want help?
Yes
No
Treatment History
How Many Times Has This User Been in Treatment for Their Addiction?
Medical History
Does The User Have Any Known Medical Conditions?
If So, Please List The Condition(s) And Any Necessary Details:
   
Has This Person Ever Been Diagnosed With Any Psychiatric Disorders?
 
If So, Is He / She Currently On Medication For A Psychiatric Disorder?
 
If So, Please Specify Medications Taken:
     
Does The User Have Medical Insurance?
 
Does The User Have Legal Issues? 
 
     

If So, Please Describe:
     

Please Provide Us With Any Other Information And Any Questions You May Have In The Area Below: