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Drug Rehab Help Line is here to help educate you on the epidemic of addiction, and to help you find the right drug rehab.

To get help to find a drug rehab please fill in the confidential case assessment form below.

Contact Us for Drug Rehab

Please fill out the form below so we can assess and refer your information to the treatment center which best suits your needs.
Call Now For Addiction Help! 1-888-781-7060
Contact Us for help finding a drug addiction treatment and rehabilitation center now!
Fill out the form below and someone will respond shortly.
Your name:
Email :
Phone #:
Address:
City: State:
Postal Code:

Person you wish to help? self other

If other, who are you concerned about:

Name:  Relationship:

How old is the addict? 

Does the addict want help? yesno

Please list drugs abused:

Primary:
Second:
Third:

How does the addict obtain drugs/alcohol ? 

Works  Steals  Prescription  Deals  Other

Please describe any personal / family problems the addict has.

Please describe any legal problems the addict has.

Please describe the overall behavior & condition of the addict.

Is there any diagnosed medical condition? (Please describe)

Is there any diagnosed mental disorder? (Please describe)

Did the addict on any medication for any of the above? 
yes no 
 

  Medication?  How long? 

Has the person ever attempted to stop using drugs before ?
yes no 

If so, by which method?

Self  12-step  Non-Hospital Residential  Hospital  Other

If the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)

Was it a private program or a state-funded program ? 
private state-funded 

Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)

Is there anything else you would like us to know?

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