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

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1. Address

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2. Full SSN

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3. What is your race?

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4. What is your gender?

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

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

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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.

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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.

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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.

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10. Are you a veteran?

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11. Which best describes your current living arrangement:

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12. Do you have a developmental disability?

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

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14. What is your marital status?

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15. How many minor children in your care?

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

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17. If yes, how many?

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18. Which best described your current legal status?

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19. Are you currently pregnant?

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

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

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22. What is your highest level of education completed?

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

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

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25. What is your current employment status?

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26. What is your current occupation?

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27. What is your current source of income? 

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28. What is your weekly income?

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29. What is your monthly income?

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

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31. Primary Drug of Use

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32. Route of Delivery

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33. Frequency of Use in the last 30 Days

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34. Age of Use for Primary Drug

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35. Secondary Drug of Use

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36. Route of Delivery for Secondary Drug of Use

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

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38. Age of Use for Secondary Drug

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

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

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

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42. What is your primary source of payment? 

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

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

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