Intake Assessment

Please fill out the form below and click submit to begin the process. We are only determining if Second Chances could be a good fit for you or your loved one’s current treatment needs. We are not here to judge your situation. We know that reaching out for help is a courageous step.

Once you have completed the online intake form and submitted it, we will review the information and contact you.

Date *

Client Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Client Date of Birth *

Client Gender *

Client Email

Client Cell Phone Number

Client Home Phone Number

Client Occupation

Can We Leave a Message?

Home
Cell

Please tick all that apply

Substances the Client is Currently Misusing *

Has the Client Been in a Substance Abuse Treatment Program Before? *

What Treatment Type is the Client Seeking? *

Will the Client be Using Insurance? *

Does the Client Have Any Current Legal Issues? *

Does the Client Have Any Major Health Issues? *

Referer's Contact Information

Referrer's Name *

First

Last

Referrer's Contact Number *

Referrer's Email *

Relationship to Patient

Intake Assessment

Referer's Contact Information

FINAL STEPS