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ABOUT
WHY CHOOSE US
WHY THE PHILIPPINES
ADDICTION TREATMENTS
PROGRAMS
Ecstasy (MDMA) Treatment and Rehab
Methamphetamine – Ice or Meth addiction Treatment
Marijuana (Cannabis) Treatment
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Heroin Treatment
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Online Assessment
BrovioJoe
2020-01-07T08:45:07+00:00
Online Assessment – For Yourself
Personal Information
First Name
Last name
Phone Number
Email Address
What is your preferred contact method?
Phone
Email
Messenger
Skype
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?
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