Friday, 03 September 2010
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Preferred Method of Contact
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If You Prefer to Contacted by Phone, Please Provide The Best Time to Call:
What is/are The Primary Drug(s) of Abuse?
Alcohol
Cocaine
Crack
Heroin
Methamphetamine
GHB
Ecstasy
Inhalants
Ketamine
Prescription Pain Killers (Morphine, OxyContin, Vicodin, Fentanyl)
Prescription Benzodiazepines (Xanax, Klonopin, Valium, etc.)
PCP
Marijuana
Methadone
LSD
Other Drug
Eating Disorder (Anorexia, Bulimia, Binge Eating, Overeating)
Other Addiction (Sexual Addiction, Gambling Addiction)
What is/are The Primary Drug(s) of Abuse? :: Check All That Apply
Drug History
At What Age Did The User First Take Drugs?
How Old Is The User Now?
What Are The Resulting Problems of The User's Addiction?
What Is The Family's Attitude Toward The User's Addiction?
Does The User Admit to Having a Problem?
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Yes
No
Not Sure
Does The User Want Help?
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Yes
No
Not Sure
Is The User Willing to Leave His/Her Home Area to Get The Best Treatment Available?
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Yes
No
Not Sure
Medical History
Has The User Been Diagnosed With Any Mental Health Problems?
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Yes
No
Not Sure
If Yes, Please List The Conditions And Any Necessary Details
Does The User Have Medical Insurance?
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Yes
No
Not Sure
If Yes, Please Select The Type of Insurance The User Has
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Private PPO Insurance
Private HMO Insurance
Medicare
Medicaid
TriCare (Military)
Other
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If Yes, Please Select The Type of Insurance The User Has :: Private health insurance is provided by companies like Blue Cross, Aetna, Cigna, and many full time employee benefits offer private PPO health insurance plans. These plans are the most likely to pay for private treatment. HMO plans are offered by the same private health insurance companies, but tend to have less sufficient inpatient substance abuse benefits - it is best to conact the insurance company to understand these benefits, as they vary for each individual plan. Medicare and Medicaid are publicly funded insurance plans and are not generally accepted at private pay treatment centers. Medicare and Medicaid will only pay for publicly funded treatment centers. Please search the treatment directory's treatment locator to find the publicly funded treatment centers in your area if the only insurance available is Medicare or Medicaid.
If Necessary, How Much Out-of-Pocket Money is Available for Private Rehab?
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None
$1 - $2500
$2500 - $5000
$5000 - $10000
$10000 - $20000
$20000 - $30000
$30000 - $40000
more than $40000
If Necessary, How Much Out-of-Pocket Money is Available for Private Rehab? :: quality private rehab starts around $10,000 for 30 days of treatment without medical isurance. If there is no money or insurance to pay for treatment, you need to look for publicly funded rehab in the user's area by using the treatent center locator in the drop down of the Treatment Directory tab.
Does The User Have Legal Issues?
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No
Not Sure
If Yes, Please Describe
Please Provide Us With Any Additional Information or Questions You May Have Here:
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