TURNING POINT TREATMENT CENTER

 

Executive Drug Alcohol Treatment

 
 
 

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Premiere Executive Drug and Alcohol Treatment CALL TODAY 877-712-6984 or 877-224-9838

Confidential assessment questionnaire. Please fill out and submit form. Someone will return a call and answer any further questions that you have. Thank you.
First Name*
Last Name
City
State
Daytime Phone() -*
Evening Phone() -
Fax() -
E-mail Address*
Comments
Relationship to Alcoholic/Addict
Alcoholics/Addicts Name
Age of individual?
Current drugs their using?
History of drugs used and when?
Past treatment attempts (what rehab, when, results)
Does anyone else have a substance abuse problem? (In the immediate family)
Marital Status (Married, Single, divorced, widowed, seperated)
List any children and ages
Who do the children live with?
Individuals occupation
Has the individual ever been terminated as a result of substance abuse? (What happened?)
Medical problems(Please list them and dates)
Is the individual currently taking any medications? (Please list and why)
Has the individual ever been diagnosed and treated for any psychological problems? (Please list and explain)
Does the individual have a valid drivers license?
Has the individual ever been arrested? (What for?) and When?
Are there any open court cases pending? Please list
Has there ever been a DUI arrest (Driving Under the Influence) When?
Does the individual require an Intervention with a Specialist? Explain
Security Code*
 
††We work with most insurance companies.

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