Upon completing the form below, someone from Recovery Strategies will be in touch with you, usually within 2 hours.
Full Name:
Cell Phone:
E-Mail:
Please confirm your email:
How did you find our website?
Last time you used opiates or benzodiazepines?:
Emergency Contact:
Your Fax:
Best Time to Contact You?
Your Address:
Address Line 2:
City:
State:
Zip Code :
Age:
Drug of Choice (DOC)
Tell us about each of the substances you have used (including alcohol), how long you have used them and the date of your last use of that particular substance:
How long have you been using overall?
How much time have you spent finding or using drugs?
Do you feel you have built up a tolerance to using drugs?
Has your drug use resulted in medical or emotionall problems?
Has your drug use resulted in legal or vocational problems?
Do you have existing medical conditions?
Have you ever been to treatment for substance abuse or addiction?
Have you ever tried to quit on your own and found that you couldnt?
Have you ever been treated by a psychiatrist?
Does anyone in your biological family have a history of substance abuse or addiction?
Are you male or female? -Male   -Female
Are you currently prescribed medications? If so, please list them here:
Are you pregnant? -Yes   -No
When was the last time you used opiates in general, methadone, morphine or oxycontin.
Where are you employed?
Do you have Insurance? If so, who is your provider and what is the number? -Yes   -No
Additional Comments:
 

Recovery Strategies, LLC
120 Center Park Drive, Suite 9
Knoxville, TN 37922
PHONE: (865) 691-1250
PHONE: 1-888-9-EZDTOX
FAX: (865) 691-1286
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E-mail: info@recoverystrategies.net


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