Online Assessment – For Yourself

Personal Information

First Name

Last name

Phone Number

Email Address

What is your preferred contact method?

What day and time best suits you?

Date of birth

Where are you located?

Drug History

What is your primary drug of choice? (Methamphetamine (Ice), Heroin, Cocaine, Marijuana, Alcohol, Prescription Drugs, Ecstasy, others…please specify)

Age when you first took drugs

Frequency of use

Quantity of use

Estimated money spent on substance of choice per week

Rehabilitation History

Please enumerate any treatment or rehabilitation received (counseling, outpatient, inpatient, where and for how long, were the treatments or programs completed, if not, reasons for incomplete treatment):

Outcome and length of sobriety

Reason/s for this enquiry:

1.For example: legal reasons, dramatic event or you reached rock bottom (please specify)

2.What are your perceived challenges in pursuing a rehab program with us?
(strength of character or financial issues or any other perceived problem-please specify)

3.How do you rate your willingness to enter rehab through Affordable Rehabs?
Rate 1-5, 5 being the highest

4.Who will be the contact person or the person within your family you designate to be the focal point of your care? Is this person willing to be the focal person during your rehab?