Confidential On-Line Treatment Referrals

The referral options provided through this tool are specific to Middlesex County, New Jersey and its immediate vicinity. If you live in another New Jersey County, please visit the New Jersey Prevention Network or call 211 for your most local referral organization. If you live outside of New Jersey, please visit the National Addiction Treatment Locator provided by the federal Substance Abuse and Mental Health Service Administration.

This tool has been designed to be used by the individual who is seeking help for themselves. Therefore, all questions will be asked in the first person. If you are seeking help for someone else, please answer the questions to the best of your ability from the perspective of the person who needs the treatment referral.

This Assessment tool will take approximately 15 minutes to complete. Please answer the following questions to the best of your ability, so we may refer you to an appropriate treatment center. When you have completed each page click the Continue button at the bottom of the page to move forward.

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?*

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?*

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?*

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

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

Help Tool

Confidential On-Line Treatment Referrals

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