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Demerol Drug Rehab
 
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Contact Us

We treat any information that you provide us as confidential. We will not disclose any medical or personal information to other drug rehab professionals.
Information gathered from this confidential assessment form is also kept in strict confodence. E-mail addresses will only be used to contact you by one of our counselor.


Assessment Form

Please fill out this short information form so that we can contact you as soon as possible. We will help you find a good rehabilitation facility with a high success rate and which method does not use any kinds of drugs in the program which actually achieves a complete rehabilitation.

Your name:
Email :
Phone #:
Address:
City: State:
Postal Code:

Person you wish to help? self other

If other, who are you concerned about:

Name:  Relationship:

How old is the addict? 

Does the addict want help? yesno

Please list drugs abused:

Primary:
Second:
Third:

How does the addict obtain drugs/alcohol ? 

Works  Steals  Prescription  Deals  Other

Please describe any personal / family problems the addict has.

Please describe any legal problems the addict has.

Please describe the overall behavior & condition of the addict.

Is there any diagnosed medical condition? (Please describe)

Is there any diagnosed mental disorder? (Please describe)

Did the addict on any medication for any of the above? 
yes no 
 

  Medication?  How long? 

Has the person ever attempted to stop using drugs before ?
yes no 

If so, by which method?

Self  12-step  Non-Hospital Residential  Hospital  Other

If the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)

Was it a private program or a state-funded program ? 
private state-funded 

Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)

Is there anything else you would like us to know?

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    This site is managed by people who want to end Demerol drug addiction.

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