Self Help Tool

Let's Get Started

Are you under a Drug Court?* Yes No

Are you currently suicidal, or do you feel as if you're a danger to yourself or others?* Yes No

Who is seeking a referral?*

Demographics

Age?*

Gender?*

Where do you live?*

What is your primary health insurance provider/payment method?*

What is your ethnic background?*

Current Enviroment

What are your current living arrangements?*

Which of the following best describes your living environment?*

What is your employment status?*

Are you currently attending a 12 Step recovery program such as Alcoholics or Narcotics Anonymous?* Yes No

How long have you been attending the program?*

Do you have a program sponsor? Yes No

History

Do you suffer from any of the following conditions?* Unmanaged diabetes
Unmanaged high blood pressure
Unmanaged seizure disorder
Managed diabetes
Managed high blood pressure
Managed seizure disorder
None of the above

Please mark the most accurate statement regarding your mental health.*

Why are you seeking addiction treatment now? (select the strongest reason)*

How long was your previous period of abstinence (non-use)?*

Details about any 12 Step Program*

Do you still have a sponsor?* Yes No

How many times have you been treated for a substance abuse problem in the past?*

Withdrawal Questions

What is your primary drug of choice?*

When was the last time you used your drug of choice?*

When you have stopped taking your drug of choice in the past, what were your primary withdrawal symptoms?*

final page which will be the results section, just not there yet

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