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Confidential Assessment Form
OPPORTUNITIES
Confidential Assessment Form
A New Beginning Starts Here.
Accepting Patients for the Treatment of Opioid & Narcotic Dependence.
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HOME
OUR LOCATIONS
Arkansas
Springdale Treatment Center
Florida
Lakeside Clinic Clearwater
Parkside Clinic Jacksonville
Illinois
Bloomington-Normal Treatment Center
Champaign Treatment Center
Peoria Treatment Center
Springfield Treatment Center
Southern Illinois Treatment Center
Indiana
Northwest Indiana Treatment Center
Kansas
Topeka Treatment Center
Nebraska
Lincoln Treatment Center
Omaha Treatment Center
South Dakota
Sioux Falls Treatment Center
OUR ANSWERS
YOUR QUESTIONS
Just What is Methadone?
WE CAN HELP
Confidential Assessment Form
OPPORTUNITIES
Confidential Assessment Form
This assessment is provided as a free public health service. A licensed alcohol and drug provider reviews all responses, and all information is strictly confidential.
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(*)
= This indicates required information on the questions that follow
Do you feel you have a drug problem?
(*)
Yes
No
Maybe
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Are you having problems at work, or school?
(*)
Yes
No
Maybe
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Are you having problems at home?
(*)
Yes
No
Maybe
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Does your family feel you have a drug problem?
(*)
Yes
No
Maybe
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Do your friends feel you have a drug problem?
(*)
Yes
No
Maybe
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Have you ever been arrested for drug related matters?
(*)
Yes
No
Maybe
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Have you ever been in drug treatment?
(*)
Yes
No
Maybe
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Have you participated in 12-step programs (AA, NA)?
(*)
Yes
No
Maybe
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Do you use every day?
(*)
Yes
No
Maybe
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Have you tried to stop using without lasting success?
(*)
Yes
No
Maybe
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Do you have medical complications from drug use (Hepatitis, HIV/AIDS, etc.)?
(*)
Yes
No
Maybe
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Have you ever been diagnosed with a psychiatric disorder?
(*)
Yes
No
Maybe
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Are you currently in treatment for any health condition – physical, mental, substance abuse?
Yes
No
Maybe
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This assessment is for:
Myself
Family
Friend
Coworker
Other
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What is the drug of choice?
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We are a specialty clinic for opioid dependency. Additional referrals may be necessary if your drug of choice is not an opioid.
What is your method of intake?
Smoke
Nasal (snorting)
Oral
Intravenous (IV)
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Do you want us to contact you?
(*)
Yes
No
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What is the best time to contact you?
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AM
PM
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May we leave a message with anyone?
(*)
YES
NO
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My First Name:
(*)
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My Last Initial:
(*)
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Email address:
(*)
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Age:
(*)
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Phone number:
(Please include area code)
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State:
(*)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
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Which Riverwood Group clinic do you want your assessment to be sent to?
(*)
Springdale, Arkansas
Clearwater, Florida
Jacksonville, Florida
Bloomington, Illinois
Champaign, Illinois
Shorewood, Illinois (Joliet)
Peoria, Illinois
Springfield, Illinois
Wood River Illinois
Northwest Indiana
Topeka, Kansas
Lincoln , Nebraska
Omaha, Nebraska
Sioux Falls Iowa
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Please enter the security code in the box below:
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