Confidential Treatment Referral Tool - Wellspring Center for Prevention

Welcome to Wellspring’s Self-Help Tool, an anonymous and confidential resource dedicated to guiding individuals affected by substance misuse toward effective treatment services.

Whether you’re seeking help for yourself or looking to support a loved one, the form below is designed to provide compassionate, personalized referrals while ensuring your privacy every step of the way.

We understand the seriousness of your situation, and we’re here to help you take that important first step towards recovery.

"*" indicates required fields

Step 1 of 5

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Who is seeking a referral?*

Email*

Your email address is required to send you your personalized treatment referrals. Wellspring Center for Prevention respects your privacy. Your email will not be shared, sold, or used for any purpose other than delivering your referral results.

Enter Email Confirm Email

Are you or the person you are filling out this form for currently suicidal, or feeling like a danger to yourself or others?*

Yes

Get Help Immediately

If you are experiencing suicidal thoughts or feel you may act on a desire to hurt someone else, please call 911 immediately and ask to be transferred to the nearest crisis center. Once you are feeling better, staff at the center will likely give you a referral to substance abuse treatment directly. If not, please feel free to return to this site for assistance with finding an appropriate referral.

Hotline and crisis phone numbers

National Suicide Hotline: 1-800-SUICIDE (800-784-2433)
New Jersey (Contact – We Care): 908-232-2880
Addiction Access Center at 844-276-2777

Middlesex County

Middlesex County Navigators: 732-745-3810
University Behavior Healthcare Hotline: 800-969-5300 or 732-235-5700
Raritan Bay Medical Center: 732-442-3794

Are you or the person you are filling out this form for under a Recovery Court?*

Yes

You Have Indicated That You Are Under A Recovery Court Ruling

Recovery court programs are rigorous, requiring intensive supervision based on frequent drug testing and court appearances, along with tightly structured regimens of treatment and recovery services. This level of supervision permits the program to support the recovery process, but also allows supervisors to react swiftly to impose appropriate therapeutic sanctions or to reinstate criminal proceedings when participants cannot comply with the program.

If you are currently involved with the Middlesex County Recovery Court, you should immediately reach out to the County’s Coordinator, Tammy D’Aloia. She can be reached by phone at 732.565.5057 or via email at tammy.daloia@judiciary.state.nj.us

Demographics

Age*

Which age group best describes you or the person you are filling out this form for?

Gender*

Which gender best describes you or the person you are filling out this form for?

Please share your gender identity

Do you or the person you are filling out this form for live in New Jersey?*

Yes

Do you or the person you are filling out this form for live in Middlesex County?*

Yes

Which township, borough, or city best describes where you or the person you are filling out this form for live?*

Health Insurance*

Which health insurance provider or payment method best applies to you or the person you are filling out this form for?

Ethnic Background*

Which ethnic background best describes you or the person you are filling out this form for?

Current Environment

Living Arrangement*

Which living arrangement best describes you or the person you are filling out this form for?

Please describe your current living arrangement

Living Environment*

Which statement best describes the living environment of you or the person you are filling out this form for?

Employment Status*

Which employment status best describes you or the person you are filling out this form for?

12-Step Recovery Program*

Are you or the person you are filling out this form for currently attending a 12-Step recovery program, such as Alcoholics Anonymous or Narcotics Anonymous?

Yes

Program Attendance*

How long have you or the person you are filling out this form for been attending the program?

Program Sponsor*

Do you or the person you are filling out this form for have a program sponsor?

Yes

History

Medical Conditions*

Do you or the person you are filling out this form for have any of the following medical conditions?

Diabetes

High blood pressure

Seizure disorder

Heart disease

Chronic pain conditions

Autoimmune disorder(s)

High cholesterol

None of the above

Mental Health*

Which statement best describes your mental health or the mental health of the person you are filling out this form for?

Primary Reason*

What is the primary reason you or the person you are filling out this form for is seeking addiction treatment now?

Period of Abstinence (non-use)*

How long was your most recent period of abstinence (non-use), or that of the person you are filling out this form for?

Additional 12-Step Program Details*

What details best describe your participation or the participation of the person you are filling out this form for in a 12-Step program?

Past Substance Use Treatment*

How many times have you or the person you are filling out this form for received treatment for a substance use problem in the past?

Withdrawal Questions

Primary Drug of Choice*

What is the primary drug of choice for you or the person you are filling out this form for?

Last Primary Drug Use*

When was the last time you or the person you are filling out this form for used the primary drug of choice?

Main Withdrawal Symptoms*

When you or the person you are filling out this form for have stopped using the primary drug of choice in the past, what were the main withdrawal symptoms?

What withdrawal symptoms do you experience?