Tennessee Drug Rehab Help Line

• Posted on October 19th, 2009

  Written by admin

   

  

  Addiction Treatment

  Thank you for taking this first step in reaching out for help.  Our referral specialists will help guide you to the addiction treatment center that is best suited to meet your needs.   We can help coordinate a smooth  and comfortable transition into drug rehab, offer instruction and advice, and provide intervention services to assist the family in handling this delicate situation successfully.  If you would rather fill out the form below, you will be contacted.  Our assessments and referrals are always confidential.

  Name

  1. Your Name(required)
  2. Email(valid email required)

  Phone

  1. Home
  2. Cell

  Address

  1. Street
  2. City
  3. State
  4. Zip

  Questions

  1. Person You Wish to Help
  2. Self Other
  3. How Old is the Person 17 or Younger 18-25 25-32 32-45 45-58 58-65 65-78 78 and Above
  4. Does the addict want help?
  5. Yes No
  6. What drug is being abused? (check all that apply)
  7. Marijuana Heroin Oxycontin Alcohol Methamphetamine Prescription Drugs Cocaine Crack
  8. Other drugs not listed?
  9. Overall behavior of the addict?
  10. Is there any diagnosed medical condition?
  11. Is there any diagnosed mental disorder?
  12. Is the addict on any medications for above?
  13. Yes No
  14. If so, what medication and how long?
  15. Has the person ever tried to stop using before?
  16. Yes No
  17. If so what method?
  18. Self 12 Step Residential
      Hospital Other
  19. If the addict has received treatment, please describe?
  20. Was it a Private Program or State Funded
  21. Private State
  22. Was their any success, how long did it last?
  23. Any other Details?

   

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