Assessment Form for Drug Addiction

Help us to know more and understand your specific needs as well as your personal, medical and addiction history. Assessments can be done through phone but we encourage you to fill out our Online Personalized Client Assessment Form.

Personal Information

E-mail Address(Required)

Name(Required)

Address

Phone Number(Required)

Date of Birth(Required)

Pre-Assessment for Drug / Alcohol Addiction

How did you hear about KAYA?(Required)

Why are you seeking treatment now instead of next week/month, etc?(Required)

Describe your current using pattern, enumerate all drugs including alcohol.(Required)

How long have you been using like this?(Required)

When is the last time you used?(Required)

What is the longest period of total abstinence from using that you’ve had in the past 5 years and why did you stop?(Required)

When you stop using do you get sick or depressed? If so, describe the symptoms.(Required)

Do you have any medical problems? If so describe:(Required)

Are you taking any medications? If so describe and supply the name of your physician. (Bring written prescriptions from your doctor when you arrive)(Required)

Have you ever been diagnosed or treated for a psychiatric disorder? If so are you prescribed any psychiatric medications?

The primary language used at the center is English. Do you have a problem with understanding, reading or writing the English language?(Required)

I can only read in English

I can only write in English

I have a good understanding of English

What other obstacles might prevent you from coming into treatment?

Is there anything that you think is important for us to know about you that we haven’t asked:

Do you feel it necessary to preform a clinical therapeutic intervention? If so would you provide us explicit permission to do so? *

Yes

Select the programs you are interested in:(Required)

4-week residential

8-week residential

12-week residential

24-week outpatient

24-week recovery coaching

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