Beacon House Beacon House

This online service is provided free of charge and all information is confidential.  We try to follow up on your assessment immediately and at least within 24 - 48 hours.  We will only identify ourselves to the contact person listed below.  If someone else answers the phone we will say that this is a personal call and we will not disclose who we are or why we are calling.

The information in the form helps us assess your needs for treatment so that we can best help you.  Filing the form out completely or disclosing personal information is not required.  However we recommend that you disclose as much information as you feel comfortable with, so that we can help you to the best of our abilities.  All information is kept completely confidential.
Confidential Online Assessment
First Name:
Last Name:
E-mail Address:
Phone Number: Ex. 123-456-7890
Evening Phone: Ex. 123-456-7890
Cell Phone: Ex. 123-456-7890
State:
   
You are seeking information about Beacon House Services for:
Self Child Spouse Sibling
Parent Friend Employee Patient
Client        
Other:         
If contacting Beacon House for someone other than yourself, please enter their name here:
   
Select your time zone:
Best time to call:
   
What is the substance(s) of choice? A.
  B.
  C.
Method of administration? A.
  B.
  C.
At what age did the user first take drugs?
How old is the user now?
At what age did the user's life begin to be unmanageable?
Presently, 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? Yes No
Does the user want help? Yes No
How many times has this user been in treatment for their addiction?
Was there any success with any of these treatment episodes, and if so, what was the length of sobriety achieved?
Does the user have any known medical conditions? Yes No
If so, please list the condition(s) and any necessary details:
Has this person ever been diagnosed with any psychiatric disorders? Yes No
If so, is he/she currently on medication for a psychiatric disorder? Yes No
If so, please specify medications taken:
Does the user have medical insurance? Yes No
Does the user have legal issues? Yes No
If so, please describe:
Please provide us with any other information and questions you may have:

 

468 Pine Avenue, Pacific Grove, CA 93950


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