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Nashville
Comfortable and beautiful residences, medically supervised detox, and full rehab services in Music City.
Austin
In-depth care to help reclaim your health and quality of life in long-term recovery in the heart of Austin.
West Palm Beach
Full scope of services, including medical detox, outpatient and residential rehab in West Palm Beach.
DC Metro
Centrally located, safe and discreet outpatient behavioral rehab, including group and one-on-one therapy.
Fort Lauderdale
Expert and compassionate outpatient rehab in comfortable, private and serene South Florida.
South Carolina
In-depth care to help reclaim your health and quality of life in long-term recovery in the heart of Charleston.
What We Treat
Anxiety
Mental Health
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Addiction
Alcohol Dependence
Bipolar
PTSD
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Virtual Pre-assessment
Step
1
of
5
20%
Name
(Required)
First
Last
DOB
(Required)
MM slash DD slash YYYY
Phone
(Required)
Substance Abuse or Mental Health
(Required)
Substance Abuse
Mental Health
Both
Why are you seeking help today?
(Required)
Substances Used:
(Required)
Alcohol
Marijuana
Cocaine
Crack
Crystal Meth
Heroin
Oxycontin
Methadone
Other Opiates
Benzodiazepines
Hallucinogens
Other Pills
Other Substance Not Listed
Alcohol Amount of Use
(Required)
How much do you use?
Alcohol Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Marijuana Amount of Use
(Required)
How much do you use?
Marijuana Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Cocaine Amount of Use
(Required)
How much do you use?
Cocaine Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Crack Amount of Use
(Required)
How much do you use?
Crack Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Crystal Meth Amount of Use
(Required)
How much do you use?
Crystal Meth Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Heroin Amount of Use
(Required)
How much do you use?
Heroin Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Oxycontin Amount of Use
(Required)
How much do you use?
Oxycontin Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Methadone Amount of Use
(Required)
How much do you use?
Methadone Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Other Opiates Amount of Use
(Required)
How much do you use?
Other Opiates Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Benzo's Amount of Use
(Required)
How much do you use?
Benzos Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Hallucinogens Amount of Use
(Required)
How much do you use?
Hallucinogens Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Other Pills Amount of Use
(Required)
How much do you use?
Other Pills Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Other Substances Amount of Use
(Required)
How much do you use?
Other Substances Frequency and Duration
(Required)
How frequently do you use the amount listed? For how long?
Date of Last Use
(Required)
MM slash DD slash YYYY
Are you court ordered treatment?
(Required)
Yes
No
Do you have any legal issues?
(Required)
Yes
No
Describe Legal Issues
(Required)
Recent or Past Medical History:
(Required)
GERD
Seizures
Hepatitis B
HIV
Cirrhosis
HTN
Diabetes Type 1
Diabetes Type 2
Asthma
Anemia
Coronary Artery Disease
Elevated Cholesterol
Elevated Liver Enzymes
Tuberculosis
HCV
Please Describe Medical Issues
(Required)
Current Weight
(Required)
Current Height
(Required)
Please list current medications:
(Required)
Past Psychiatric Diagnosis:
(Required)
Anxiety
Depression
Bipolar Disorder
ADHD/ADD
Schizophrenia
PTSD
Borderline Personality Disorder
Dissociative Identity Disorder
Auditory Hallucinations
Visual Hallucinations
Areas Affected by Mental Health
(Required)
Self
Relationships
Employment
School
Plan or Intent of Suicide or Self Harm?
(Required)
Current OR Past attempts or plan. Please explain. Include any current or past plan, intent, and or means.
Plan or Intent of Violent Actions?
(Required)
Current or past thoughts or actions. Include thoughts or attempts of homicide. If current, include plan, intent, and means For past thoughts, include date, method, and disposition.
History of Trauma or Abuse?
(Required)
Yes
No
Current Living Situation
(Required)
Family
Alone
Halfway House
Homeless
Another Program
Hospital
Employment Status
(Required)
Employed
Not Employed
SSI/SSDI
Student
Retired
Where are you located?
(Required)
Include city and state
Do you have any financial support?
(Required)
Yes
No
Have you been to treatment before?
(Required)
Yes
No
How Many Times?
(Required)