Assessment Form
Because we understand that seeking addiction resources and treatment information can be confusing and often uncomfortable, we have chosen to provide a  no pressure and confidential form to help us better assess your situation that you can fill out in the privacy of your own home.  The more we know about you or your loved one’s needs that better we can address the problem and provide the best level of care.  

Please use the link below to fill out as much information as you can on the situation. Someone will call or email you back quickly to being working with you to get help for yourself or someone you care about.  

 It is important to include any insurance information as well.  If you don't have insurance it is no problem we will find the appropriate resources right away. We will get everyone the help they desperately need.  

We are available 24/7 and can provide free, confidential, no pressure assessments.

Sign in to Google to save your progress. Learn more
What do you need help with today?
Is this information for:
Clear selection
Please tell us about the situation.
You can give a brief description of the problem and the person involved and what sort of resource you are hoping to get.  It is ok if you are unsure or unable to provide full details.  Our addiction experts will work with the information you provide and if needed will contact you for an additional information that was not previously provided.  
Name of the person needing treatment:
Birth date of the person needing treatment:
City and State:
Contact phone number for yourself and/or the person in need of treatment:
Health insurance company:
Policy number:
Group number:
Phone number on the back of the insurance card:
If multiple numbers please provide the number for substance abuse or behavioral health.
Name and birth date of the person insured:
Fill this out if the person needing treatment is under a spouse or parent.  We will need the name and birth date of the person who is the primary insurance holder.
If uninsured-- Does the person have employement, family or friends that may be able to help finance treatment if a partial scholarship is available?
This information does not gaunrentee that a scholarship will be available, nor does it hold you or the person in need responsible for the cost of treatment at this time.  This will help us gauge what level of care can be considered.  Often if someone without insurance is able to get some financial support we can immediately get them into a quality program and avoid wait list at state facilities.
How did you hear about us?
When is the best time to contact you?
How would you like to be contacted?
Clear selection
Contact name *
Contact email *
Contact phone *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms