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".

Your name *

E-Mail address *

Phone # Home

Phone # Work

Phone # Cell

Best time to call

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Addict's First Name

Drug of Choice #1 Alcohol Addiction Cocaine Addiction Crack Addiction Codeine Addiction Crack Addiction Darvocet Addiction Demerol Addiction Dexedrine Addiction Dilaudid Addiction Ecstasy Addiction GHB Addiction Heroin Addiction Hydrocodone Addiction Lortab Addiction Marijuana Addiction Meth Addiction Methadone Addiction Morphine Addiction Opiate Addiction Opium Addiction OxyContin Addiction Percocet Addiction Percodan Addiction Ritalin Addiction Rohypnol Addiction Rohypnol Addiction Ultram Addiction Vicodin Addiction Other addiction

Drug of choice #2 Alcohol Rehab Cocaine Rehab Cocaine Rehab Crack Rehab Codeine Rehab Darvocet Rehab Demerol Rehab Dexedrine Rehab Dilaudid Rehab Ecstasy Rehab GHB Rehab Heroin Rehab Hydrocodone Rehab Lortab Rehab Marijuana Rehab Meth Rehab Methadone Rehab Morphine Rehab Opiate Rehab Opium Rehab OxyContin Rehab Percocet Rehab Percodan Rehab Ritalin Rehab Rohypnol Rehab Ultram Rehab Vicodin Rehab Other drugs

Is Addict seeking help Yes No

List any Drug rehab program previously attended and if treatment was completed Detox completed Detox incomplete 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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