Drug Rehab Help Line

For Help call 1-877-801-5475

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Assessment Form
Please fill out this information form. All the information provided is held in strict confidence. The Drug Rehab Helpline will assist you in finding a good drug or alcohol rehabilitation facility to achieve complete rehabilitation.
*Your Name:
*Email :
*Phone #:
Address:
City: State:
Postal Code:

Person you wish to help? self other

If other, who are you concerned about:

Name:  Relationship:

How old is the addict? 

Does the addict want help? yesno

Please list drugs abused:

Primary:
Second:
Third:

How does the addict obtain drugs/alcohol ? 

Works Steals Prescription Deals  Other

*Please describe any personal / family problems the addict has.

Please describe any legal problems the addict has.

Please describe the overall behavior & condition of the addict.

Is there any diagnosed medical condition? (Please describe)

Is there any diagnosed mental disorder? (Please describe)

Did the addict on any medication for any of the above? 
yes no 
 

  Medication?  How long? 

Has the person ever attempted to stop using drugs before ?
yes no 

If so, by which method?

Self 12-step Non-Hospital  Hospital  Other

If the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)


Was it a private program or a state-funded program ? 
private state-funded 

Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)

Is there anything else you would like us to know?

Doctor Drug Rehab .us

Drug Rehab Staff

This is a confidential drug rehab help line designed to help find a facility for many kinds of addictions.

Drug Rehab.us
For Help call 1-877-801-5475