Please complete the following assessment. When finished it will send the responses to our admissions department. Thanks!

Question Title

* 1. Address

Question Title

* 2. Full SSN

Question Title

* 3. What is your race?

Question Title

* 4. What is your gender?

Question Title

* 5. Have you ever felt the need to bet more and more money?

Question Title

* 6. Have you ever had to lie to people important to you about how much you gamble?

Question Title

* 7. At this time, how important is receiving treatment for alcohol use?

Not at all Moderately Extremely
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 8. At this time, how important is receiving treatment for drug use?

Not at all Moderately Extremely
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 9. At this time, how important is receiving treatment for mental health issues?

Not at all Moderately Extremely
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 10. Are you a veteran?

Question Title

* 11. Which best describes your current living arrangement:

Question Title

* 12. Do you have a developmental disability?

Question Title

* 13. Have you used tobacco in the last 30 days?

Question Title

* 14. What is your marital status?

Question Title

* 15. How many minor children in your care?

Question Title

* 16. Have you had children previously removed from your custody or who are currently placed with Department of Family Services?

Question Title

* 17. If yes, how many?

Question Title

* 18. Which best described your current legal status?

Question Title

* 19. Are you currently pregnant?

Question Title

* 20. In the last 30 days, how many times have you been arrested?

Question Title

* 21. In your lifetime, how many times have you been arrested for DUI?

Question Title

* 22. What is your highest level of education completed?

Question Title

* 23. If you attended special education classes, please include which best described your situation:

Question Title

* 24. Are you currently enrolled in school or job training? 

Question Title

* 25. What is your current employment status?

Question Title

* 26. What is your current occupation?

Question Title

* 27. What is your current source of income? 

Question Title

* 28. What is your weekly income?

Question Title

* 29. What is your monthly income?

Question Title

* 30. Please check any public assistance that you are currently receiving.

Question Title

* 31. Primary Drug of Use

Question Title

* 32. Route of Delivery

Question Title

* 33. Frequency of Use in the last 30 Days

Question Title

* 34. Age of Use for Primary Drug

Question Title

* 35. Secondary Drug of Use

Question Title

* 36. Route of Delivery for Secondary Drug of Use

Question Title

* 37. Frequency of Use in the last 30 Days for Secondary Drug of Use

Question Title

* 38. Age of Use for Secondary Drug

Question Title

* 39. How many detox programs have you attended in your lifetime?

Question Title

* 40. How many residential or inpatient substance use treatment programs have you attended in your lifetime? 

Question Title

* 41. How many outpatient programs have you attended in your lifetime?

Question Title

* 42. What is your primary source of payment? 

Question Title

* 43. In the last 30 days, how many days have you attended a self-help program?

Question Title

* 44. What medication are you currently taking for addiction treatment?

0 of 66 answered
 

T