Assessment and Treatment
Referral Service for New York

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:
  1. Prior alcohol and drug use history;
  2. Family history and Ethnic/Cultural background;
  3. Social history;
  4. Legal history;
  5. Educational history;
  6. Occupational history;
  7. Medical history;
  8. 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:
drugs and alcohol addictionYour Name:
drugs and alcohol addictionDay Phone #: drugs and alcohol addictionEvening #:
     Best Time to Call:
drugs and alcohol addictionEmail :
drugs and alcohol addictionAddress:
drugs and alcohol addictionCity: drugs and alcohol addictionState: drugs and alcohol addictionZip Code:
drugs and alcohol addictionYour Relation to the Alcoholic/Addict:
     If Other Please Specify:

drugs and alcohol addictionAlcoholics/Addicts Name:

drugs and alcohol addictionCity and State in which they live:

drugs and alcohol addictionCan they travel outside of this area for treatment?  yes  no

drugs and alcohol addictionHow old is the addict ?

drugs and alcohol addictionCurrent drug (s) their using:

A). Substance Abuse History:

drugs and alcohol addictionAt what age did the individual start using the substance?

drugs and alcohol addictionDifferent drugs used:

drugs and alcohol addictionMethod of use:  
       Oral     IV-(inject)     inhale(smoke)     nasal(snort)     Other

drugs and alcohol addictionPast treatment attempts (What rehab, when, results:

B). Family History:

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

drugs and alcohol addictionAny losses (death) or departures (divorce-separations) from the family institution?

drugs and alcohol addictionEthnic/cultural background: 
      (Alaskan or Indian)
C). Social History

drugs and alcohol addictionMarital status:

drugs and alcohol addictionAny children?  yes  no

drugs and alcohol addictionwho has parenting responsibilities?

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

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

drugs and alcohol addictionHas the individuals peer structure changed?  yes  no

D). Legal History:

drugs and alcohol addictionDoes the individual have a valid drivers license?  yes  no

drugs and alcohol addictionHas the individual ever been arrested? (If so, for what)

drugs and alcohol addictionAre any crimes actively being committed to support, or as a result of the alcoholism or addiction?

E). Educational History:

drugs and alcohol addictionHighest grade completed in grade school :

drugs and alcohol addictionVocational Tech?  yes  no

drugs and alcohol addictionAny desire or plan of continued or future education?

F). Occupational History
drugs and alcohol addictionOccupation: drugs and alcohol addictionHow Long?

drugs and alcohol addictionIs this the individuals chosen occupation?  yes  no

     If no what is?

drugs and alcohol addictionHas the individual ever been terminated as a result of substance abuse?  yes  no

G). Medical History:

drugs and alcohol addictionDoes the individual have any medical problems? (Please describe)

drugs and alcohol addiction Is the individual currently taking any medications?  yes  no

     If yes, please specify what and length of use:

H). Psychological and Behavioral History:

drugs and alcohol addictionHas the individual ever been diagnosed and treated for any psychological or emotional problems?  yes  no

drugs and alcohol addictionIf yes, please specify what and when and outpatient or inpatient;

drugs and alcohol addictionWas the individual prescribed medication for any psychological/emotional problem ?  yes  no

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

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

drugs and alcohol addictionAdditional Information or Comments


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