Find a doctor/ therapist

One of our specialists will conduct a brief assessment to help determine which doctor can best meet your needs.  Please call to receive your assessment.

-Or you can fill out this needs questionnaire and one of our specialists will contact you to complete the assessment and make recommendations.

Name * :

Telephone * :

Your Email * :

Gender :
 M F

Age :

Drug(s) of Choice :

Days sober :

Are you currently prescribed any controlled substances? :
 Yes No

If yes please provide a list :

Are you currently on Suboxone/ Subutex maintenance? :
 Yes No

Do you have a dog or other pet? :
 Yes No

Do you have any medical conditions that require special attention? :
 Yes No

If yes please explain :

Please rank the following 9 factors in order of importance to you in selecting a halfway house (9 is the least important and 1 is the most important) :

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