New York Drug Rehabilitation Programs
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Contact Us Assessment Form Your Name: Email : Phone #: Cell #: Work #: Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Country: Postal Code: Person you wish to help ? self other          If other, who are you concerned about:      Name:  Relationship: husband wife father mother son daughter grandparent friend other How old is the addict ?  less than 18 18 - 25 26 - 35 36 - 45 46 - 55 56 - 65 over 65   Does the addict want help ? yes no  Please list drugs abused:  Primary: Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants  Ketamine  LSD Marijuana Methadone  PCP  Prescription Drugs Other Second: Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants  Ketamine  LSD Marijuana Methadone  PCP  Prescription Drugs Other Third: Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants  Ketamine  LSD Marijuana Methadone  PCP  Prescription Drugs Other 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?      Please fill out this information form as completely as possible so that we can provide you with the best help possible. We will help you find a good rehabilitation facility with a high success rate and which method does not use any kinds of drugs in the program which actually achieves a complete rehabilitation. Top

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This Web site is provided to find drug rehab centers, drug addiction treatment, drug rehabilitation, drug and alcohol rehab centers, drug treatment centers or any drug rehab programs that works. Resources updated Jan 8/06

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