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Online Assessment

Your responses for the assessment below are kept completely secret and confidential by our doctors and staff. This short assessment will help us determine how to help you or your loved one. You can expect contact from one of our friendly staff within 24 hours:
Please take the time to fill out our "Drug Addiction Assessment" form below to allow us to help you in the best way possible. The more information we know about you, the better we can help and the easier it is for you in the long run. If you are not comfortable with this form or these questions, then please fill out our Basic Information form.
Your First Name:  
Your Last Name:  
Email Address :  
State:  
Phone: Type:
Inquiring About:  
Age of addict:  
Individual's First Name:  
Individual's Last Name:  
Individual's State:  

Primary Drug: Last Used:
Amount: Method:
Other Drug: Last Used:
Amount: Method:
Briefly describe the drug history of the addict:
What problems has addiction caused the addict?
What problems has addiction caused the family?
What kind of help do you think the addict needs?
Current Medications:
Other Comments :
 
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"I have been so grateful that I came to this program. It was a hard road but this program made me open up to my problems honestly. First I had to look at them from the outside but then I started looking at them from the inside. What a difference! I can't express enough gratitude to my counselors for their help in this journey. I never dreamed that I could think differently about my disease and myself. Thank you so much!"
- Finance Manager  

Online Treatment:
1-877-E-Wayout
1-877-392-9688

24/7 Inpatient:
1-800-368-6865

 
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