Online Assessment

Please take the time to fill out our "Drug Addiction Assessment" form below to allow us to help you in the best way possible. The more information we know about you, the better we can help and the easier it is for you in the long run. If you are not comfortable with this form or these questions, then please fill out our Basic Information form.

Your First Name:
Your Last Name:
Email Address :
State:
Phone:		Type:
Inquiring About:
Age of addict:
Individual's First Name:
Individual's Last Name:
Individual's State:

Primary Drug:		Last Used:
Amount:		Method:
Other Drug:		Last Used:
Amount:		Method:
Briefly describe the drug history of the addict:
What problems has addiction caused the addict?
What problems has addiction caused the family?
What kind of help do you think the addict needs?
Current Medications:
Other Comments :

24/7 Inpatient:
1-800-368-6865

"For a long time drugs were my game. Now I am sober thanks to The Living Center which helped me to get back on my feet."

- P.P.

"Thanks to TLC and counselors there has been a big change in my life. I now have a job; I am sober; I don’t even have a craving to use."

- J.M.

"At The Living Center, if you want to get clean, they can help, if you are unsure as I was, they will give you the tools you need to make an educated decision. I couldn’t have done it without [them], now my life is back on track and I am in a new living program called pathway to independence. If it wasn’t for The Living Center I would be back out on the streets."

- T.K.

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