Lewiston Drug Treatment Facility

Drug  Treatment Programs Oregon         This online service is provided free of charge as a public benefit service and all information received from clients is confidential. Response time is usually 24 hours or less, and is in the form of a confidential e-mail. In some instances phone contact may be appropriate and necessary to better assess the situation, or in the case of an emergency where the call was requested by the individual. In the event of a phone call the counselor will only identify themselves to the contact person listed below, and will advise all others that this a personal call and will not disclose who we are or why we are calling. In assessing the problem and deciding on treatment options, several factors that are typically used in assessing an individual's level of addiction. These factors include: Prior alcohol and drug use history; Family history and Ethnic/Cultural background; Social history; Legal history; Educational history; Occupational history; Medical history; Psychological and behavioral problems. Below you will find questions pertaining to these areas, it is important that you answer them as accurately as possible. This information is requested, however it is not required for a referral: Please fill-out the form below so we can assess and refer your information to the treatment center which best suits your needs. Code 42 of Federal Regulations forbids parishioners to disclose the identities of persons inquiring about drug rehab services - even if they are never admitted to the facility.

General and Contact Information: Your Name: Day Phone #: Evening #:      Best Time to Call: Email : Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code: Your Relation to the Alcoholic/Addict: self son/daughter spouse parent friend employee other      If Other Please Specify: Alcoholics/Addicts Name: City and State in which they live: Can they travel outside of this area for treatment?  yes  no How old is the addict ? less than 18 18 - 25 26 - 35 36 - 45 46 - 55 56 - 65 over 65 Current drug (s) their using:       A). Substance Abuse History: At what age did the individual start using the substance? Different drugs used:       Method of use:          Oral     IV-(inject)     inhale(smoke)     nasal(snort)     Other Past treatment attempts (What rehab, when, results:        B). Family History: Does anyone in the alcoholics/addicts immediate (blood) family have/or had a substance abuse problem?  yes  no Any losses (death) or departures (divorce-separations) from the family institution?       Ethnic/cultural background:    Asian-      American   Native-American       (Alaskan or Indian)   Euro-American       (Caucasian)   African-      American C). Social History Marital status: single married divorced widowed Any children?  yes  no who has parenting responsibilities? Has the individual enjoyed any social activities in the past? (if yes, specify)       Has there been a gradual shift to non-involvement in those activities? (if yes, when)       Has the individuals peer structure changed?  yes  no D). Legal History: Does the individual have a valid drivers license?  yes  no Has the individual ever been arrested? (If so, for what)       Are any crimes actively being committed to support, or as a result of the alcoholism or addiction?       E). Educational History: Highest grade completed in grade school : 1 2 3 4 5 6 7 8 9 10 11 12 Some College College Graduate Vocational Tech?  yes  no Any desire or plan of continued or future education?       F). Occupational History Occupation: How Long? Is this the individuals chosen occupation?  yes  no      If no what is? Has the individual ever been terminated as a result of substance abuse?  yes  no G). Medical History: Does the individual have any medical problems? (Please describe)       Is the individual currently taking any medications?  yes  no      If yes, please specify what and length of use:       H). Psychological and Behavioral History: Has the individual ever been diagnosed and treated for any psychological or emotional problems?  yes  no If yes, please specify what and when and outpatient or inpatient;        Was the individual prescribed medication for any psychological/emotional problem ?  yes  no       If yes, please list what drugs where prescribed and length of use:        On a Scale of 1-10, with 10 representing extreme urgency, and 1 representing information for later use. Please assign a number to this request : 1 2 3 4 5 6 7 8 9 10 Additional Information or Comments

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