This online service is provided free of charge as a public benefit service and all information received from clients is confidential. Response time is usually 24 hours or less, and is in the form of a confidential e-mail. In some instances Solutions For Recovery services may attempt phone contact to better assess the situation or if it an extreme emergency exists and the call was requested. In the event of a phone call Solutions For Recovery services will only identify themselves to the contact person listed below, and will advise all others that this a personal call and will not disclose who we are or why we are calling.

There are several areas to be considered when assessing for substance abuse/dependence. Each of these areas creates variable factors that should be considered when making a determination for treatment and placement. Below you will find questions pertaining to these areas, it is important that you answer them as accurately as possible.

The below request for information is requested, however it is not required for a referral.

General and Contact Information:

Your Name: Day Phone #: Evening #: Best Time to Call:   Email : Address: City:   State: CA AK AL AR AZ 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 Zip Code: Your Relation to the Alcoholic/Addict: self son/daughter spouse parent friend employee other If Other Please Specify: Alcoholics/Addicts Name: City and State in which they live: Can they travel outside of this area for treatment? yes   no How old is the addict ? less than 18 18 - 25 26 - 35 36 - 45 46 - 55 56 - 65 over 65   Current drug (s) their using:                 I. Substance Abuse History:         At what age did the individual start using the substance? Different drugs used:       Method of use:              Oral     IV-(inject)     inhale(smoke)     nasal(snort)     Other Past treatment attempts (what rehab, when, results):               II. Family History:         Does anyone in the alcoholics/addicts immediate (blood) family have/or had a substance abuse problem?   yes   no     Any losses (death) or departures (divorce-separations) from the family recently?   Ethnic/cultural background:       Asian-      American   Native-American       (Alaskan or Indian)   Euro-American       (Caucasian)   African-      American           III. Social History         Marital status: single married divorced widowed     Any children? yes   no   Who has parenting responsibilities? Has the individual enjoyed any social activities in the past? (if yes, specify)   Has there been a gradual shift to non-involvement in those activities? (if yes, when)   Has the individuals peer structure changed?   yes   no               IV. Legal History:         Does the individual have a valid drivers license?     yes   no     Has the individual ever been arrested? (if so, for what)     Are any crimes actively being committed to support, or as a result of the alcoholism or addiction?             V. Educational History:         Highest grade completed in grade school :   1 2 3 4 5 6 7 8 9 10 11 12 Some College College Graduate     Vocational Tech? yes   no   Any desire or plan of continued or future education?               VI. Occupational History         Occupation: How Long? Is this the individuals chosen occupation?     yes   no     If no what is? Has the individual ever been terminated as a result of substance abuse? yes   no               VII. Medical History:         Does the individual have any medical problems? (please describe)   Is the individual currently taking any medications?   yes   no     If yes, please specify what and length of use:               VIII. Psychological and Behavioral History:         Has the individual ever been diagnosed and treated for any psychological or emotional problems?   yes   no     If yes, please specify what and when and outpatient or inpatient;   Was the individual prescribed medication for any psychological/emotional problem ?   yes   no     If yes, please list what drugs where prescribed and length of use:   On a Scale of 1-10, with 10 representing extreme urgency, and 1 representing information for later use. Please assign a number to this request : 1 2 3 4 5 6 7 8 9 10       Additional Information or Comments