Drug Rehab – Call us now at 800-501-9330 to speak with a drug addiction treatment counselor.

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ABOUT ADDICTION

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DRUG REHABILITATION ASSESSMENT FORM

Fill out the form below, and one of our chemical dependency counselors will conduct a thorough assessment of your situation and provide you with the best course of action to help yourself or a loved one. Drug Rehab Center Hotline is an online service here to assist you with drug addiction help and resources. Please fill out the form below and one of our drug addiction treatment counselors will contact you. All information received is confidential. Response time is usually within 12 hours from the time you submit your information. For a quicker response, you can call our toll-free number 800-501-9330.

Please supply as much information as possible so we can best help you with your situation.

Contacts name: First

Last

Email Address:

Phone # home

cell work

Best Method of contact: email home cell work / best time to contact

Addicts Name: First

Last Optional

How is the addict related to you? The addict is my:

Addicts Drug of choice:

Second Drug of choice:

Other drugs used :

Select State:

Addicts Age:

Does addict wants help?

Has Addict ever recieved treatment? What type?

Is there any diagnosed mental disorder? (Please describe)

Present situation:

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