Long-Term Drug Rehab Assessment Form

Please fill out this information form as completely as possible so that we can provide you with the best help possible. We will help you find a good rehabilitation facility with a high success rate and which method does not use any form of drugs in the program and which actually achieves a complete rehabilitation.

All information is held in strict confidence. You confidentiality is protected by Federal Law.

For immediate assistance to find a longterm drug rehabilitation center, call now 1-888-781-7060. You may also fill out the form below and a professional counselor will assist you as soon as possible.

Any names and/or files transmitted with this form are confidential and are intended solely for the use of the individual or entity to which they are addressed. This communication may contain material protected by HIPAA legislation (45 CFR, Parts 160 & 164). If you are not the intended recipient or the person responsible for delivering this email to the intended recipient, be advised that you have received this email in error and that any use, dissemination, forwarding, printing or copying of this email is strictly prohibited. If you have received this email in error, please notify the sender by replying to this email and then delete the email from your computer.