Confidential Assessment Form

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Confidential Assessment Form

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Confidential Assessment Form

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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..

(*) = 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

Invalid Input

Do your friends feel you have a drug problem?(*)

Yes

No

Maybe

Invalid Input

Have you ever been arrested for drug related matters?(*)

Yes

No

Maybe

Invalid Input

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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AMPM

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May we leave a message with anyone?(*)

YESNO

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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:(*)

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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

Peoria, 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:(*)

<b><br>Please enter the security code in the box below:</b>

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