Online Assessment Form
All information is confidential
* Required
Area
*
Choose
Macomb County
Bay-Midland-Saginaw Counties
Chippewa County
Clinton County
Crawford County
Eaton County
Genesee County
Grand Traverse
Ingham County
Lapeer County
New York - Hudson Valley Area
Oakland County
Otsego County
St. Clair County
Wayne County
Other
If other, please specify
Your answer
Gender
*
Male
Female
D.O.B.
*
MM
/
DD
/
YYYY
What type of service are you needing?
*
Detox
Treatment
Both
Required
First Name
*
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Address
Your answer
City
Your answer
County
*
Your answer
State
Your answer
Zip Code
Your answer
Who are you looking for services for?
*
Self
Family Member
Friend
Volunteer Angel on behalf of participant
Required
How did you hear about the Hope Not Handcuffs Program?
Your answer
If you're currently in a hospital, which hospital are you in?
*
NA
Beaumont Farmington
Beaumont Grosse Pointe
Beaumont Royal Oak
Beaumont Troy
Beaumont Wayne
McLaren Flint
McLaren Lansing
McLaren Macomb
MidMichigan Medical Center
Other:
Do you currently have health insurance
*
Yes
No
Carrier
Your answer
Insurance Number
Your answer
Mental Health Diagnosis?
Your answer
All information is kept confidential and is property of Families Against Narcotics for Hope Not Handcuffs Recovery Program a 501c3 non profit.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
