Contact New York Drug Rehab

New York drug rehab contactPlease fill out the form below for more information on how to get drug rehab help for yourself or someone else in New York. Your information is completely confidential and we will do a no-charge assessment and referral with you by phone when one of our counselors responds to your request for help.

Your Name:
Email :
Phone #:
Cell #:
Work #:
Address:
City: State:
Country:
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 ? yes no 

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 Residential  Hospital  Other

If the addict has received treatment, please describe it. (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?


    

We will be sure to reply as quickly as possible to help you with drug rehab options in New York. Thank you.