CONFIDENTIAL ONLINE ASSESSMENT

New Life is here to help you. Our knowledgeable addictions counselors are available at 1-866-894-6572. Complete the form below. We strive to provide treatment and/or appropriate referrals to all those in need. The assessment process is completely confidential, and free of charge.

When we make a phone call we will only identify ourselves to the contact person listed below. If someone else answers the phone we will say that this is a personal call and we will not disclose who we are or why we are calling.
 

All information submitted is completely confidential and protected
by 42CFR under the Federal Guidelines of Client Confidentiality.

*Required Fields

  CONTACT INFORMATION
 
First Name:

*
  Last Name:

*
  Phone Number: *
  E-Mail: *
  State: *
  Best time to contact: *
  You Are Contacting Us For:
 

If Contacting Us For Someone Other Than
Yourself, Please Enter Their Name:
 



DRUG AND ALCOHOL HISTORY
 

What Is The Primary Drug of Abuse?

 *
  Method of Intake: *
  How Often?: *
  Current Age of User? *
  At What Age Did The User First Take Drugs?: *
 

At What Age Did The User's Life Begin To Be Unmanageable?
  Describe Current Problems or Concerns:
  Does The User Admit To Having A Problem?:
  Do You Or The User Want Help?:
 



TREATMENT HISTORY
 

How Many Treatment Attempts For The 
User's Addiction?:
 
How Many Treatment Attempts Involved 
A 12-Step Model?:
  What Were The Results of These Prior Attempts 
(i.e. any sobriety, and if so how long, etc.)?:
 



MEDICAL HISTORY

  
  Please List Any Medical Conditions The User 
May Have. Be Sure To Include Mental Health 
Diagnosis (if applicable):
  List any Prescribed Medication the User is Taking?
  If User Has Medical Insurance, Who Is The 
Insurance Carrier?:
 



OTHER INFO:

  
  Does The User Have Any Current Legal Problems?:
  If There Are Legal Problems, Please Describe:
  Please Provide Any Other Pertinent Information 
That You Feel Is Important:
 

 

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