ONLINE REQUEST FORM
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. If you leave a phone number, we will make one attempt to contact you. If there is no answer or you are not available, we will send you an e-mail to make further contact. 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.
Please fill the form and a certified counselor will contact you. If you do not want a counselor to reach you over the phone. Do not fill the field of "phone".
Phone # Home
Phone # Work
Phone # Cell
Best time to call
Province or State
Addict's First Name
Drug of Choice #1
Drug of choice #2
Is Addict seeking help
List any Drug rehab program previously attended and if treatment was completed
Drug Rehab Outpatient incomplete
Drug Rehab Outpatient completed
Drug Rehab Long Term Incomplete
Drug Rehab Long Term completed
Drug Rehab residential incomplete
Drug Rehab Residential incomplete
Drug Rehab Twelve steps
Drug Rehab Religious
Half Way House
Add any other information regarding Drug Rehab Program previously done.
Describe any medication history past or present(Name,Length, dosage etc.).
Describe addicted person's history (hospitalizations, psychiatric evaluations, present illnesses etc.)
Describe addicted person's legal history. (current & past charges or incarceration}
Type any questions or comments below on Crack Cocaine Treatment.
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