ASSESSMENT SURVEY

Find out how we can help you

Fill out the simple assessment form below. It only takes a few minutes and we will get back to you within the hour with information on how we can help. (* indicates required fields)

1. Who do you know that needs treatment? *
	Self
	Son/daughter
	Husband/wife
	Friend
	Co-worker
	Other
2. What are you struggling with? (Choose all that apply)
	Alcohol
	Drugs
	Both Alcohol & Drugs
	Anxiety
	Mood: (Depression, Mania or Bipolar)
	Eating: (Anorexia, Bulimia or Binge Eating)
	Other
3. Do you think you need a detox? *
--Please select-- Yes No Don't know
4. Have you been in treatment before? *
--Please select-- Never Once before Many times
5. What else do you need that might help you get sober or assist your situation? *
	Legal help
	Family support and involvement
	Extended care (more than 30 days)
	Intervention
	Physical Care (Yoga, Massage, Exercise, Nutritionist, etc.)
	Continued Care (Sober living, Outpatient)
	General Healthcare
	Psychiatric Assessment
	Physical Disability
	Other
6. Please enter contact information so we can get back to you with our personalized assessment. Don't worry. All information is confidential.
First name * Last name Postal code Email address * Phone number