Drug Rehab Colorado

Assessment and Treatment
Referral Service Colorado

This online service is provided free of charge as a public benefit service and all information received from clients is confidential. Response time is usually 24 hours or less, and is in the form of a confidential e-mail. In some instances phone contact may be appropriate and necessary to better assess the situation, or in the case of an emergency where the call was requested by the individual. In the event of a phone call the counselor will only identify themselves to the contact person listed below, and will advise all others that this a personal call and will not disclose who we are or why we are calling. In assessing the problem and deciding on treatment options, several factors that are typically used in assessing an individual's level of addiction. These factors include:

Prior alcohol and drug use history;
Family history and Ethnic/Cultural background;
Social history;
Legal history;
Educational history;
Occupational history;
Medical history;
Psychological and behavioral problems.
Below you will find questions pertaining to these areas, it is important that you answer them as accurately as possible. This information is requested, however it is not required for a referral:

Please fill-out the form below so we can assess and refer your information to the treatment center which best suits your needs. Code 42 of Federal Regulations forbids parishioners to disclose the identities of persons inquiring about drug rehab services - even if they are never admitted to the facility.

General and Contact Information:

Your Name:

Day Phone #: Evening #:

     Best Time to Call:

Email :

Address:

City: State: Zip Code:
Your Relation to the Alcoholic/Addict:

     If Other Please Specify:

Alcoholics/Addicts Name:

City and State in which they live:

Can they travel outside of this area for treatment? yes no

How old is the addict ?

Current drug (s) their using:

A). Substance Abuse History:

At what age did the individual start using the substance?

Different drugs used:

Method of use:

       Oral   IV-(inject)   inhale(smoke)   nasal(snort)   Other

Past treatment attempts (What rehab, when, results:

B). Family History:

Does anyone in the alcoholics/addicts immediate (blood) family have/or had a substance abuse problem? yes no

Any losses (death) or departures (divorce-separations) from the family institution?

Ethnic/cultural background:

Asian-
     American Native-American
      (Alaskan or Indian) Euro-American
      (Caucasian) African-
     American
C). Social History

Marital status:

Any children? yes no

who has parenting responsibilities?

Has the individual enjoyed any social activities in the past? (if yes, specify)


Has there been a gradual shift to non-involvement in those activities? (if yes, when)


Has the individuals peer structure changed? yes no
D). Legal History:
Does the individual have a valid drivers license? yes no

Has the individual ever been arrested? (If so, for what)


Are any crimes actively being committed to support, or as a result of the alcoholism or addiction?

E). Educational History:

Highest grade completed in grade school :

Vocational Tech? yes no

Any desire or plan of continued or future education?

F). Occupational History

Occupation: How Long?

Is this the individuals chosen occupation? yes no

     If no what is?

Has the individual ever been terminated as a result of substance abuse? yes no
G). Medical History:

Does the individual have any medical problems? (Please describe)


Is the individual currently taking any medications? yes no

     If yes, please specify what and length of use:

H). Psychological and Behavioral History:
Has the individual ever been diagnosed and treated for any psychological or emotional problems? yes no

If yes, please specify what and when and outpatient or inpatient;


Was the individual prescribed medication for any psychological/emotional problem ? yes no

      If yes, please list what drugs where prescribed and length of use:


On a Scale of 1-10, with 10 representing extreme urgency, and 1 representing information for later use. Please assign a number to this request :

Additional Information or Comments

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Assessment and Treatment Referral Service Colorado

Assessment and Treatment
Referral Service Colorado