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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

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

Not at all Moderately Extremely

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

Not at all Moderately Extremely

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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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